AH4 - Week 13 - Lippincott NCLEX Review Ch. 3 Test 17 Emergencies, Mass Casualties, Disasters - Exam 3

24. A severe acute respiratory syndrome (SARS) epidemic is suspected in a community of 10,000 people. As clients with SARS are admitted to the hospital, what type of precautions should the nurse institute? 1. Enteric precautions. 2. Hand-washing precautions. 3. Reverse isolation. 4. Standard precautions.

4. Standard precautions. Transmission o SARS can be contained by ollowing standard (universal) precautions, which include masks, gowns, eye protection, hand wash- ing, and sae disposal o needles and sharps. The disease is spread by the respiratory, not enteric, route. Hand washing alone is not sucient to pre- vent transmission. Reverse isolation (protection o the client) is not sucient to prevent transmission.

27. A number of clients have come to the emergency department after a possible terrorist act of arsenic overexposure. The nurse should assess these clients for which signs or symptoms immediately following the poisoning? Select all that apply. 1. Violent vomiting. 2. Severe diarrhea. 3. Abdominal pain. 4. Sensory neuropathy. 5. Persistent cough.

1, 2, 3 1. Violent vomiting. 2. Severe diarrhea. 3. Abdominal pain. When arsenic overexposure occurs, the signs and symptoms include violent nausea, vomiting, abdominal pain, skin irritation, severe diarrhea, laryngitis, and bronchitis. Dehydration can lead to shock and death. Ater the acute phase, bone marrow depression, encephalopathy, and sensory neuropathy occur.

14. Thirty people are injured in a train derailment. Which client should be transported to the hospital first? 1. A 20-year-old who is unresponsive and has a high injury to his spinal cord. 2. An 80-year-old who has a compound fracture of the arm. 3. A 10-year-old with a laceration on his leg. 4. A 25-year-old with a sucking chest wound.

4 During a disaster, the nurse must make difficult decisions about which persons to treat first. The guidelines for triage offer general priorities for immediate, delayed, minimal, and expectant care. The client with a sucking chest wound needs immediate attention and will likely survive. The 80-year-old is classified as delayed; emergency response personnel can immobilize the fracture and cover the wound. The 10-year-old has minimal injuries and can wait to be treated. The client with a spinal cord injury is not likely to survive and should not be among the first to be transported to the health care facility.

7. The American Heart Association (AHA) and Canadian Heart and Stroke Foundation guidelines urge greater availability of automated external defibrillators (AEDs) and people trained to use them. AEDs are used in cardiac arrest situations for: 1. Early defibrillation in cases of atrial fibrillation. 2. Cardioversion in cases of atrial fibrillation. 3. Pacemaker placement. 4. Early defibrillation in cases of ventricular fibrillation

4. Early defibrillation in cases of ventricular fibrillation AEDs are used for early defibrillation in cases of ventricular fibrillation. The AHA and Canadian Heart and Stroke Foundation place major emphasis on early defibrillation for ventricular fibrillation and use of the AED as a tool to increase sudden cardiac arrest survival rates.

33. The nurse notices a pair of nervous-acting individuals entering the emergency department. When reporting suspicious activity, the nurse should include which of the following in the report? Select all that apply. 1. Vehicle/s description. 2. Current location of parties involved. 3. Names and phone numbers of parties involved. 4. Relationship to hospitalized client. 5. Tone of voice of each party involved.

1, 2 . Vehicle/s description. 2. Current location of parties involved. All suspicious individuals or activities should be reported as soon as possible to the secu- rity department. When reporting an incident, nurses/ employees should provide the ollowing: (a) type o incident; (b) persons involved/physical descrip- tion; (c) vehicles involved and description; (d) date and time the incident occurred; (e) location where the incident occurred; () weapons involved; and (g) current location o parties involved. All reports o threats, actual episodes o violence, or suspicious individuals or activities must be investigated.

23. A suspected outbreak of anthrax has been transmitted by skin exposure. A client is admit- ted to the emergency department with lesions on the hands. The physician prescribes antibiotics and sends the client home. What should the nurse instruct the client to do? Select all that apply. 1. Take the prescribed antibiotics for 60 days. 2. Avoid contact with other members of the family during the treatment period. 3. Wear a mask for 60 days. 4. Expect the skin lesions to clear up within 1 to 2 weeks. 5. Wash hands frequently

1, 4 1. Take the prescribed antibiotics for 60 days. 4. Expect the skin lesions to clear up within 1 to 2 weeks. Anthrax is treated with antibiotics, and the client must continue the prescription or 60 days, even i symptoms do not persist. The client may have skin lesions at the point o contact, with macula or papule ormation; the eschar will all o in 1 to 2 weeks. Clients with anthrax are not conta- gious; the client does not need to ollow isolation procedures at home. Anthrax rom skin exposure is not transmitted by respiratory contact, and the client does not need to wear a mask.

4. A middle-aged man collapses in the emergency department waiting room. The triage nurse should first: 1. Gently shake the victim and ask him to state his name. 2. Perform the chin-tilt to open the victim's airway. 3. Feel for any air movement from the victim's nose or mouth. 4. Watch the victim's chest for respirations.

1. Gently shake the victim and ask him to state his name. Calling the victim's name and gently shaking the victim is used to establish unresponsiveness. The head-tilt, chin-lift maneuver is used to open the victim's airway. Feeling for any air movement from the victim's nose or mouth indicates whether the victim is breathing on his own. The rescuer can watch the victim's chest for respirations to see if the victim is breathing.

2. A client is admitted to the emergency department with a full-thickness burn to the right arm. Upon assessment, the arm is edematous, fingers are mottled, and radial pulse is now absent. The client states that the pain is 8 on a scale of 1 to 10. The nurse should: 1. Administer morphine sulfate IV push for the severe pain. 2. Call the physician to report the loss of the radial pulse. 3. Continue to assess the arm every hour for any additional changes. 4. Instruct the client to exercise his fingers and wrist.

2. Call the physician to report the loss of the radial pulse. Circulation can be impaired by circumferential burns and edema, causing compartment syndrome. Early recognition and treatment of impaired blood supply is key. The physician should be informed since an escharotomy (incision through full-thickness eschar) is frequently performed to restore circulation. Pain management is important for burn clients, but restoration of circulation is the priority. Assessments should be performed more frequently. Exercise will not restore the obstructed circulation.

16. An apartment fire spreads to seven apartment units. Victims suffer burns, minor injuries, and broken bones from jumping from windows. Which client should be transported first? 1. A woman who is 5 months pregnant with no apparent injuries. 2. A middle-aged man with no injuries who has rapid respirations and coughs. 3. A 10-year-old with a simple fracture of the humerus who is in severe pain. 4. A 20-year-old with first-degree burns on her hands and forearms.

2. The man with respiratory distress and coughing should be transported first because he is probably experiencing smoke inhalation. The pregnant woman is not in imminent danger or likely to have a precipitous delivery. The 10-year-old is not at risk for infection and could be treated in an outpatient facility. First-degree burns are considered less urgent.

22. The nurse in the emergency department is triaging the following victims of an airplane crash. Prioritize the clients in the order in which they should be treated. 1. A 75-year-old with a 2-inch (5.1-cm) laceration to the left forearm. 2. A 22-year-old with a 2-inch (5.1-cm) laceration to the left temple, slightly confused. 3. A 14-year-old with a 2-inch (5.1-cm) laceration to chin, history of asthma, respirations 26, audible wheezing. 4. A 22-year-old female, 36 weeks pregnant with contractions every 10 to 15 minutes.

3, 2, 4, 1 3. A 14-year-old with a 2-inch (5.1-cm) laceration to chin, history of asthma, respirations 26, audible wheezing 2. A 22-year-old with a 2-inch (5.1-cm) laceration to the left temple, slightly confused. 4. A 22-year-old female, 36 weeks pregnant with contractions every 10 to 15 minutes. 1. A 75-year-old with a 2-inch (5.1-cm) laceration to the left forearm. The 14-year-old with asthma needs immediate, lie- saving interventions or the wheezing and should be seen rst. The 22-year-old who is conused should be seen next to assess or head injury; the location o the laceration could indicate a signicant blunt orce traumatic injury. The pregnant emale requires assessment but is not urgent unless other symptoms appear. The 75-year-old is nonurgent and can wait saely or several hours.

6. Proper hand placement for chest compressions during cardiopulmonary resuscitation (CPR) is essential to reduce the risk of which complication? 1. Gastrointestinal bleeding. 2. Myocardial infarction. 3. Emesis. 4. Rib fracture.

4. Proper hand placement during chest compressions is essential to reduce the risk of rib fractures, which may lead to pneumothorax and other internal injuries. Gastrointestinal bleeding and myocardial infarction are generally not considered complications of CPR. Although the victim may vomit during CPR, this is not associated with poor hand placement, but rather with distention of the stomach.

20. A small airplane crashes in a neighborhood of 10 houses. One of the victims appears to have a cervical spine injury. What should first aid for this victim include? Select all that apply. 1. Establish an airway with the jaw-thrust maneuver. 2. Immobilize the spine. 3. Logroll the victim to a side-lying position. 4. Elevate the feet 6 inches (15.2 cm). 5. Place a cervical collar around the neck

1, 2 1. Establish an airway with the jaw-thrust maneuver. 2. Immobilize the spine. The victim o a neck injury should be immobilized and moved as little as possible. It is also important to ensure an open airway; this can be accomplished with the jaw-thrust maneuver, which does not require tilting the head. The victim should not be rolled to a side-lying position nor have his eet elevated. Both actions can cause additional injury to the spinal cord. Placing a cervical collar causes movement o the spinal column and should not be done as a rst-aid measure.

34. There has been an increase in medication errors and errors in prescribing laboratory studies in the emergency department. The nurse manager is conducting a staff education session on when to use "read-back" procedures. "Read-back" procedures should be performed in which of the following situations? Select all that apply. 1. When a medication prescription or critical laboratory result is received verbally or over the telephone. 2. When any verbal or phone prescription is received. 3. Whenever a written prescription or printed critical test result is received. 4. When the unit secretary takes a phone prescription. 5. When the agency uses computerized health care records.

1, 2 1. When a medication prescription or critical laboratory result is received verbally or over the telephone. 2. When any verbal or phone prescription is received. A goal o client saety is to improve the eectiveness o communication among caregivers. For verbal or telephone prescriptions, or or tele- phone reporting o critical test results, one must veriy the complete prescription or test result by having the individual receiving the inormation record "read-back" the complete prescription or test result. The Unit Secretary is not a licensed health care proessional who has a Scope o Practice or the authority to receive prescriptions or results. The type o charting system used by the health care agency is not a actor in using "read-back" prescriptions.

18. An airplane crash results in mass casualties. The nurse is directing personnel to tag all victims. Which information should be placed on the tag? Select all that apply. 1. Triage priority. 2. Identifying information when possible (such as name, age, and address). 3. Medications and treatments administered. 4. Presence of jewelry. 5. Next of kin.

1, 2, 3 1. Triage priority. 2. Identifying information when possible (such as name, age, and address). 3. Medications and treatments administered. Tracking victims o disasters is important or casualty planning and management. All victims should receive a tag, securely attached, that indicates the triage priority, any available identiying inormation, and what care, i any, has been given along with time and date. Tag inorma- tion should be recorded in a disaster log and used to track victims and inorm amilies. It is not necessary to document the presence o jewelry or next o kin.

12. The nurse in the emergency department reports there is a possibility of having had direct contact with blood of a client who is suspected of having HIV/AIDS. The nurse requests that the client have a blood test. Consent for human immunodefiency virus (HIV) testing can only be completed when which of the following circumstances are present? Select all that apply. 1. An emergency medical provider has been exposed to the client's blood or body fuids. 2. Testing is prescribed by a physician under emergency circumstances. 3. Testing is prescribed by a court, based on evidence that the client poses a threat to others. 4. Testing is done on blood collected anonymously in an epidemiologic survey. 5. When a health care provider who is taking care of a client who is suspected of having HIV/AIDS requests a blood test.

1, 2, 3, 4. Upon a physician's written prescription requesting an HIV test for a client, consent for HIV testing must be obtained. Consent exceptions include the following: testing is prescribed by a physician under emergency circumstances, and the test is medically necessary to diagnose or treat the client's condition; testing is prescribed by a court, based on clear and convincing evidence of a serious and present health threat to others posed by an individual; testing is done on blood collected or tested anonymously as part of an epidemiologic survey; or an emergency medical provider has been exposed to the client's blood or body fluids.

15. An explosion at a chemical plant produces flames and smoke. More than 20 persons have burn injuries. Which victims should be transported to a burn center? Select all that apply. 1. The victim with chemical spills on both arms. 2. The victim with third-degree burns of both legs. 3. The victim with first-degree burns of both hands. 4. The victim in respiratory distress. 5. The victim who inhaled smoke.

1, 2, 4, 5. Victims with chemical burns, second- and third-degree burns over more than 20% of their body surface area, and those with inhalation injuries should be transported to a burn center. The victim with first-degree burns of the hands can be treated with first aid on the scene and referred to a health care facility

3. A client is brought to the emergency department with abdominal trauma following an automobile accident. The vital signs are as follows: HR 132, RR 28, BP 84/58, temp 97.0°F (36.1°C), and oxygen saturation 89% on room air. Which of the following prescriptions from the health care provider should the nurse implement first? 1. Administer 1 L 0.9% normal saline IV. 2. Draw a complete blood count (CBC) with hematocrit and hemoglobin. 3. Obtain an abdominal x-ray. 4. Insert an indwelling urinary catheter.

1. Administer 1 L 0.9% normal saline IV. The client is demonstrating vital signs consistent with fluid volume deficit, likely due to bleeding and/or hypovolemic shock as a result of the automobile accident. The client will need intravenous fluid volume replacement using an isotonic fluid (eg, 0.9% normal saline) to expand or replace blood volume and normalize vital signs. The other prescriptions can be implemented once the intravenous fluids have been initiated.

21. Thirty-two children are brought to the emergency department after a school bus accident. Two children were killed along with the three people in the car that caused the crash. Before the victims arrive, in addition to ensuring that the hospital staff are prepared for the emergency, which step should the nurse anticipate carrying out? 1. Calling the nearest crisis response team. 2. Alerting the news media. 3. Notifying the hospital volunteer office. 4. Calling the school to inform teachers of the accident.

1. Calling the nearest crisis response team. The children and their amilies are at risk or experiencing a crisis. Disaster teams are avail- able or crisis intervention in such emergencies. Usually the news media monitors emergency radio requencies and most likely are aware o the acci- dent already. Although volunteers may help in some ways, they are not responsible or crisis interven- tion. Calling the school might be done, but the emer- gency issues take precedence

25. Several clients who work in the same building are brought to the emergency department. They all have fever, headache, a rash over the entire body, and abdominal pain with vomiting and diarrhea. Upon initial assessment, the nurse finds that each client has low blood pressure and has developed petechiae in the area where the blood pressure cuff was inflated. Which isolation precautions should the nurse initiate? 1. Contact isolation with double-gloving and shoe covers. 2. Respiratory isolation with positive pressure rooms. 3. Enteric precautions. 4. Reverse isolation.

1. Contact isolation with double-gloving and shoe covers. The nurse should institute treatment or hemorrhagic ever viruses, including contact isola- tion with double-gloving and shoe covers, strict hand hygiene, and protective eyewear. The nurse should start respiratory isolation with negative pres- sure rooms, not positive pressure rooms. Enteric precautions are not needed because the virus is spread by droplet and contact. Reverse isolation protects the client; in this situation, the health care team also needs protection.

32. The nurse in the emergency department is administering a prescription for 20 mg intravenous furosemide (Lasix) which is to be given immediately. The nurse scans the client's identification band and the medication barcode. The medication administration system does not verify that furosemide is prescribed for this client; however, the furosemide is prepared in the accurate unit dose for intravenous infusion. The nurse should do which of the following next? 1. Contact the pharmacist immediately to check the prescription and the barcode label for accuracy. 2. Administer the medication now, knowing the medication is labeled and the client is identified. 3. Report the problem to the information tech- nology team to have the barcode system recalibrated. 4. Ask another nurse to verify the medication and the client so the medication can be given now

1. Contact the pharmacist immediately to check the prescription and the barcode label for accuracy. The nurse should contact the pharmacist rst to be sure the medication is labeled or admin- istration to this client. The nurse should not admin- ister the drug until all saety precautions have been observed; the nurse should also not ask another nurse to veriy the medication or client. Later, i the problem cannot be resolved with relabeling the medication, the nurse or pharmacist can contact the inormation technology team to check the barcode system.

11. A client is brought to the emergency room via ambulance accompanied by her sister. The sister states, "She was playing cards with us and had a seizure. Then she had another seizure just as the first one was stopping, so I called the ambulance." The client is currently not demonstrating any seizure activity, her eyes are closed, and she does not respond to commands. Which intervention should the nurse implement first? 1. Make sure suction equipment is set up bedside. 2. Draw blood for a phenytoin (Dilantin) level. 3. Assess the client's vital signs. 4. Prepare the client for a head computed tomography (CT).

1. Following a seizure (postictal stage), the client will most likely be tired and want to sleep. Maintaining the airway is the priority; the nurse should verify that suction equipment is available in case the client aspirates or chokes. Assessing vital signs and obtaining a Dilantin level are both appropriate actions by the nurse, but assuring safety is the first priority. There is no indication of a need to obtain a head CT at this time.

29. The nurse is triaging victims of an earthquake who were removed from a building when the earthquake occurred. Which of the following victims should be classified as red? Select all that apply. 1. A 10-year-old male with crushing chest wound, tachypnea with labored breathing, unconscious, impaled object in forehead. 2. A 49-year-old male with crushing chest pain radiating to the jaw, is diaphoretic, nauseated, and has an open fracture of the left wrist. 3. A 75-year-old female with obvious fracture of the femur, absent pedal pulses on the affected side; heart rate 110, respirations 34, skin diaphoretic; awake/alert, states pain is 10 on a scale of 1 to 10. 4. A 32-year-old female who is unconscious, 3-inch (7.6-cm) laceration to her forehead, ecchymosis behind the ears, respiratory rate 10/shallow; radial pulse is weak/thread/ rapid; no breath sounds on the right side.

2, 3 2. A 49-year-old male with crushing chest pain radiating to the jaw, is diaphoretic, nauseated, and has an open fracture of the left wrist. 3. A 75-year-old female with obvious fracture of the femur, absent pedal pulses on the affected side; heart rate 110, respirations 34, skin diaphoretic; awake/alert, states pain is 10 on a scale of 1 to 10. The client with crushing chest pain has an acute cardiac condition and can have a successul outcome i immediate interventions are initiated. The client with the open racture could be stabilized and is not a signicant actor in triage in a mass casualty incident. The client with a displaced emur racture can also be classied as immediate because the racture can impair circula- tion. There are also signs o shock and severe pain. All conditions can improve with interventions. In a mass casualty incident, the goal is to do the great- est good or the greatest number—which sometimes means that limited resources are not allocated to the very critically injured that have a very low probability o survival. The other two clients are categorized as "black"/expectant because o their critical injuries and the unavailability o advance trauma care.

17. There is a shooting in a shopping mall. Three victims with gunshot wounds are brought to the emergency department. What should the nurse do to preserve forensic evidence? Select all that apply. 1. Cut around blood stains to remove clothing. 2. Place each item of clothing in a separate paper bag. 3. Hang wet clothing to dry. 4. Refrain from documenting client statements. 5. Place bullets in a sterile container.

2, 3 2. Place each item of clothing in a separate paper bag. 3. Hang wet clothing to dry. Preserving orensic evidence is essen- tial or investigative purposes ollowing injuries that may be caused by criminal intent. The nurse should put each item o clothing in a separate paper bag and label it; wet clothing should be hung to dry. The nurse should not cut or otherwise unnecessarily handle clothing, particularly cloth- ing with such evidence as blood or body fuids. The nurse should document careully the client's description o the incident and use quotes around the client's exact words where possible. The docu- mentation will become a part o the client's record and can be subpoenaed or subsequent investiga- tion. The nurse should not handle bullets rom the client because they are an important piece o orensic evidence

26. Several clients come to the emergency depart- ment with suspected contamination by the Ebola virus. What should the nurse do? Select all that apply. 1. Call in extra staff to assist with the possibility of more clients with the same condition. 2. Isolate all the suspected clients in the emergency department in one area. 3. Call housekeeping for diluted household bleach. 4. Restrict visitors from the emergency department. 5. Quarantine all contacts.

2, 3, 4 2. Isolate all the suspected clients in the emergency department in one area. 3. Call housekeeping for diluted household bleach. 4. Restrict visitors from the emergency department. The nurse should isolate all the sus- pected clients in the emergency department in one area and restrict visitors rom the emergency depart- ment to minimize exposure to others. The nurse should also obtain diluted household bleach (1:100) to decontaminate areas suspected o coming in contact with the virus. There is no indication at this time that extra sta is needed, so the nurse should not call in extra sta, to minimize exposure to health care workers. It is not necessary to quarantine contacts until a diagnosis is conrmed. In addition, it is the role o the public health ocer to issue the quarantine i needed.

9. A client has been admitted to the emergency department diagnosed with food poisoning following an outdoor picnic. The nurse should do which of the following? Select all that apply. 1. Tell the family to discard contaminated food. 2. Collect specimens for laboratory examination. 3. Assess vital signs. 4. Initiate support for the respiratory system. 5. Monitor fluid and electrolyte status. 6. Provide antiemetics, as prescribed.

2, 3, 4, 5, 6. Food poisoning is a sudden illness that occurs after ingestion of contaminated food or drink. The nurse should first assess vital signs and then ensure that the client is not in respiratory distress, because death from respiratory paralysis can occur with botulism, fish poisoning, and other food poisonings. Measures to control nausea are important to prevent vomiting, which could exacerbate fluid and electrolyte imbalance. Because large volumes of electrolytes and water are lost by vomiting and diarrhea, fluid and electrolyte status needs to be continuously monitored. The key to treatment is determining the source and type of food poisoning. If possible, rather than discarding the food, the suspected food should be brought to the medical facility and a history obtained from the client or family.

31. A client who was a victim of a gunshot wound was treated in the emergency department and died. What should the nurse direct the unlicensed assistive personnel (UAP) to do during postmortem care? Select all that apply. 1. Remove all tubes and IV lines. 2. Cover the body with a sheet. 3. Notify the family. 4. Transport the body to the morgue. 5. Notify the chaplain.

2, 4 2. Cover the body with a sheet. 4. Transport the body to the morgue. The UAP can cover the body and trans- port it to the morgue. Deaths by gunshot wound are considered reportable deaths. All evidence in a reportable death, including tubes and IV lines, should remain intact until the coroner has been con- tacted. The health care provider should be the one to notiy the amily. The nurse should be the one to notiy the chaplain

5. A client is experiencing an allergic response. The nurse should do which of the following in order from first to last? 2. Assess the airway and breathing pattern. 3. Notify the physician. 4. Activate the rapid response team. 1. Assess for urticaria

2,1,4,3 If a client is experiencing an allergic response, the nurse's initial action is to assess the client for signs/symptoms of anaphylaxis, first checking the airway, breathing pattern and vital signs, with particular attention to signs of increasing edema and respiratory distress. The nurse should then assess for other indications of anaphylaxis, such as urticaria, feelings of impending doom or fright, weakness, sweating (because a severe systemic response to an allergen can result in massive vasodilation), increased capillary permeability, decreased perfusion, decreased venous return, and subsequent decreased cardiac output. The nurse should call the rapid response team and then notify the physician

1. Three hours ago, a client was thrown From a car into a ditch, and he is now admitted to the emergency department in a stable condition with vital signs within normal limits, alert and oriented with good coloring and an open fracture of the right tibia. For which signs and symptoms should the nurse be especially alert? 1. Hemorrhage. 2. Infection. 3. Deformity. 4. Shock.

2. Because of the degree of contamination of the open fracture and the time that has passed since the accident, the risk of infection is very high. Therefore, the nurse should be especially alert for signs and symptoms of possible existing infection or early signs of infections, such as debris in the wound site, temperature abnormalities, results of laboratory studies (such as complete blood cell count and wound culture and sensitivities), or heat or redness around or in the wound. Because the client's vital signs and cardiovascular status are stable at this time, hemorrhage is not the primary concern. The client is talking coherently at this point, so his mentation does not suggest that he is in shock. However, assessment for signs and symptoms of hemorrhage and shock would certainly be ongoing. The fracture would be corrected by surgery as soon as possible, thereby minimizing the risk of deformity.

19. A car accident involves four vehicles on a remote highway. The nearest emergency department is 15 minutes away. Which victim should be trans- ported by helicopter to the nearest hospital? 1. A 10-year-old with a simple fracture of the femur who is crying and cannot find his parents. 2. Middle-aged woman with cold, clammy skin and a heart rate of 120 bpm who is unconscious. 3. Middle-aged man with severe asthma and a heart rate of 120 bpm who is having difficulty breathing. 4. A 70-year-old man with a severe headache who is conscious.

2. Middle-aged woman with cold, clammy skin and a heart rate of 120 bpm who is unconscious. The middle-aged woman is likely in shock. She is classied as a triage level I, requiring immediate care. The child with moderate trauma is classied as triage level III (urgent and should be treated within 30 minutes). The man with asthma and the man with the severe headache are classied as triage level II (emergent) and can be transported by ambulance and reach the hospital within 15 minutes.

28. Eight farm workers are admitted to the emergency department after they were splashed with "a couple of chemicals" at work 30 minutes ago. They have watery/itchy eyes, slight cough, diaphoresis, constricted pupils, and are conscious and oriented. Their clothes are wet. What action should the nurse do first? 1. Apply oxygen at 3 L per nasal cannula. 2. Remove their clothing. 3. Begin decontamination shower. 4. Isolate the clients.

4. Isolate the clients. Saety o the sta and others is the rst priority. By isolating the clients, this reduces the chance o contaminating others (secondary contami- nation). Vital signs can be obtained when it is sae— ater protecting sta, patients, and visitors rom secondary contamination. Oxygen is not indicated or any o the listed symptoms. Removing cloth- ing is important to prevent urther exposure to the client, but must be done in a sae manner to prevent secondary contamination to others. The clients can remove their own clothes and place them in plas- tic bags. Ater the saety o the sta and others is addressed, AND the acility is prepared and prop- erly trained sta is ready, the clients can be given a decontamination shower. I the sta is not trained, 911 may be the most appropriate response. Finding out which chemicals were involved is important, but does not take priority over preventing secondary contamination.

10. A client is admitted to the emergency department after being found in a daze walking away from her burning car after an accident. She was not injured in the accident, but the other driver died. She states, "I can't handle it anymore. There's no point to it all." The crisis nurse recommends hospital admission based on the identification of which of the following concerns? 1. The client was walking around in a daze. 2. The client has a lack of knowledge of what to do next. 3. The client is having delusions and is not in touch with reality. 4. The client is expressing helplessness and hopelessness and is a risk for suicide.

4. The client is expressing helplessness and hopelessness and is a risk for suicide. The client is demonstrating helplessness and hopelessness during a crisis, as evidenced by her statement, "I can't handle it. There is no point to it." Feelings of helplessness and hopelessness are common factors associated with suicidal ideation. Therefore, the client must be hospitalized to ensure safety to herself. There is not sufficient information to know if the client has a lack of knowledge of what to do next. The client is not having delusions, which would be evidenced by statements such as "The devil set my car on fire," not just the inability to think clearly.