Test 3 Disaster nursing- NCLEX
The wounded victim is able to walk and obey commands. The wounded victim is assigned what tag color? A. Green B. Red C. Yellow D. Black
The answer is A: Green.
Which statement below is INCORRECT about the yellow triage tag color in regards to a disaster situation? A. A survivor with this tag color is seen after patients with the green tag color. B. A survivor with this tag color can have treatment delayed for an hour or less. C. A survivor with this tag color has serious injuries that could eventually lead to the compromise of breathing, circulation, or mental status, especially if treatment is delayed more than an hour or so. D. A survivor with this tag color has second priority for treatment of injuries.
The answer is A. This statement is INCORRECT. It should say: A survivor with this tag color is seen after patients with the RED (not green) tag color.
For the next 7 questions, use the START method for adults to help triage the wounded that have been involved in a disaster situation. Each question will give you details on what you have assessed and you will need to use those details to help you assign a color tag to the individual: The wounded victim is unable to walk, has respiratory rate of 40, capillary refill is 6 seconds, and can't follow simple commands. The wounded victim is assigned what tag color? A. Green B. Red C. Yellow D. Black
The answer is B: Red.
The wounded victim is unable to walk, has respiratory rate of 12, capillary refill is 8 seconds, and is unresponsive. The wounded victim is assigned what tag color? A. Green B. Red C. Yellow D. Black
The answer is B: Red.
When attending a client with a head and neck trauma following a vehicular accident, the nurse's initial action is to? A. Do oral and nasal suctioning. B. Provide oxygen therapy. C. Initiate intravenous access. D. Immobilize the cervical area.
D Immobilize the cervical area. Clients with suspected or possible cervical spine injury must have their neck immobilized until formal assessment occurs. Options A, B, and C: Suctioning, oxygen therapy, and intravenous access are also done after the cervical spine is immobilize.
The wounded victim is unable to walk, has respiratory rate of 19, capillary refill of one second, and is able to obey your commands. The wounded victim is assigned what tag color? A. Green B. Red C. Yellow D. Black
The answer is C: Yellow.
A client in a one-car rollover presents with multiple injuries. Prioritize the interventions that must be initiated for this patient. 1. Assess for spontaneous respirations. 2. Give supplemental oxygen per mask. 3. Insert a Foley catheter if not contraindicated. 4. Obtain a full set of vital signs. 5. Remove patient's clothing. 6. Secure/start two large-bore IVs with normal saline. 7. Use the chin lift or jaw thrust method to open the airway. A. 1, 7, 2, 6, 4, 5, 3 B. 7, 1, 4, 2, 3, 5, 6 C. 4, 1, 5, 7, 6, 3, 2 D. 5, 4, 1, 7, 2, 6, 3
A. 1, 7, 2, 6, 4, 5, 3 For a trauma client with multiple injuries, many interventions will occur simultaneously as team members assist in the resuscitation. Assessing for spontaneous respirations, performing techniques to open the airway such as chin lift or jaw thrust, and applying oxygen may occur simultaneously. However, in the nursing process, recall that first you must assess, then you intervene. Opening the airway must precede the administration of oxygen because, if the airway is closed, the oxygen cannot enter the air passages. Starting IV lines for fluid resuscitation is part of supporting circulation. (Emergency medical service personnel will usually establish at least one IV line in the field.) UAPs can be directed to measure vital signs and remove clothing. Insertion of a Foley catheter is necessary for close monitoring of output. Focus: Prioritization
You are assessing a patient who has sustained a cat bite to the left hand. The cat is up-to-date immunizations. The date of the patient's last tetanus shot is unknown. Which of the following is the priority nursing diagnosis? A. Risk for Impaired Mobility related to potential tendon damage. B. Risk for Infection related to organisms specific to cat bites. C. Ineffective Health Maintenance related to immunization status. D. Impaired Skin Integrity related to puncture wounds.
B Risk for Infection related to organisms specific to cat bites. Cat's mouths contain a virulent organism, Pasteurella multocida, that can lead to septic arthritis or bacteremia. Options A and D: There is also a risk for tendon damage due to deep puncture wounds. These wounds are usually not sutured. Option C: A tetanus shot can be given before discharge.
You are caring for a client with a frostbite on the feet. Place the following interventions in the correct order. 1. Immerse the feet in warm water 100° F to 105° F (40.6º C to 46.1° C). 2. Remove the victim from the cold environment. 3. Monitor for signs of compartment syndrome. 4. Apply a loose, sterile, bulky dressing. 5. Administer a pain medication. A. 5, 2, 1, 3, 4 B. 2, 5, 1, 4, 3 C. 2, 1, 5, 3, 4 D. 3, 2, 1, 4, 5
B. 2, 5, 1, 4, 3 The client should be removed from the cold environment first, then the rewarming process can be initiated. It will be painful, so pain medication should be given before immersing the feet in warm water. A loose, sterile, bulky bandage should be applied to the area after warming to protect the feet. The client should be monitored for compartment syndrome every hour after initial treatment. Focus: Prioritization
An ER nurse is handling a 50-year-old woman complaining of dizziness and palpitations that occur from time to time. ECG confirms the diagnosis of paroxysmal supraventricular tachycardia. The client seems worried about it. Which of the following is an appropriate response of the nurse? A. "You can be discharged now; this is a probable sign of anxiety." B. "You have to stay here for a few hours to undergo blood tests to rule out myocardial infarction." C. "We'll need to keep you for further assessment; you may develop blood clots." D. "The physician will prescribe you blood-thinning medications to lessen the episodes of palpitations."
C. Paroxysmal supraventricular tachycardia (PSVT) is characterized by episodes of rapid heart rate that occurs periodically and stops on its own. PSVT decreases the cardiac output and can result to a thrombus. These clots could turn into an embolus, which could eventually lead to a stroke.
Michael works as a triage nurse, and four clients arrive at the emergency department at the same time. List the order in which he will assess these clients from first to last. 1. A 50-year-old female with moderate abdominal pain and occasional vomiting. 2. A 35-year-old jogger with a twisted ankle, having a pedal pulse and no deformity. 3. An ambulatory dazed 25-year-old male with a bandaged head wound. 4. An irritable infant with a fever, petechiae, and nuchal rigidity A. 1, 2, 3, 4 B. 2, 1, 3, 4 C. 4, 3, 1, 2 D. 3, 4, 2, 1
C. 4, 3, 1, 2 An irritable infant with fever and petechiae should be further assessed for other meningeal signs. The patient with the head wound needs additional history and assessment for intracranial pressure. The patient with moderate abdominal pain is uncomfortable but not unstable at this point. For the ankle injury, a medical evaluation can be delayed 24 - 48 hours if necessary.
A 65-year-old patient arrived at the triage area with complaints of diaphoresis, dizziness, and left-sided chest pain. This patient should be prioritized into which category? A. Non-urgent. B. Urgent. C. Emergent. D. High urgent.
C. Emergent Chest pain is considered an emergent priority, which is defined as potentially life-threatening. Option B: Clients with urgent priority need treatment within 2 hours of triage (e.g. kidney stones). Option A: Non-urgent conditions can wait for hours or even days. Option D: High urgent is not commonly used; however, in 5-tier triage systems, High urgent patients fall between emergent and urgent in terms of the time elapsing prior to treatment.
A client arrived at the emergency department after suffering multiple physical injuries including a fractured pelvis from a vehicular accident. Upon assessment, the client is incoherent, pale, and diaphoretic. With vital signs as follows: temperature of 97°F (36.11° C), blood pressure of 60/40 mm Hg, heart rate of 143 beats/minute, and a respiratory rate of 30 breaths/minute. The client is mostly suffering from which of the following shock? A. Cardiogenic. B. Distributive. C. Hypovolemic. D. Obstructive
C. Hypovolemic Hypovolemic shock occurs when the volume of the circulatory system is too depleted to allow adequate circulation to the tissues of the body. A fractured pelvis will lose about one liter of blood hence symptoms such as hypotension, tachycardia, and tachypnea will occur. Option A: Causes of cardiogenic include massive myocardial infarction or other cause of primary cardiac (pump) failure. Option B: Distributive shock results from a relative inadequate intravascular volume caused by arterial or venous vasodilation. Option D: Obstructive shock is a form of shock associated with physical obstruction of the major vessels or the heart itself.
In relation to submersion injuries, which task is most appropriate to delegate to an LPN/LVN? A. Talk to a community group about water safety issues. B. Stabilize the cervical spine for an unconscious drowning victim. C. Remove wet clothing and cover the victim with a warm blanket. D. Monitor an asymptomatic near-drowning victim.
D Monitor an asymptomatic near-drowning victim. The asymptomatic patient is currently stable but should be observed for delayed pulmonary edema, cerebral edema, or pneumonia. Options A and B: Teaching and care of critical patients are an RN responsibility. Option C: Removing clothing can be delegated to a nursing assistant.
When conducting a primary survey on a trauma patient, which of the following is considered one of the priority elements of the primary survey? A. Initiation of pulse oximetry. B. Complete set of vital signs. C. Client's allergy history. D. Brief neurologic assessment.
D Brief neurologic A brief neurologic assessment to determine the level of consciousness and pupil reaction is part of the primary survey. Vital signs, client's allergy, and initiation of pulse oximetry are considered part of the secondary survey.
You respond to a call for help from the ED waiting room. There is an elderly patient lying on the floor. List the order for the actions that you must perform. 1. Call for help and activate the code team. 2. Instruct a nursing assistant to get the emergency cart. 3. Initiate cardiopulmonary resuscitation (CPR). 4. Perform the chin lift or jaw thrust maneuver. 5. Establish unresponsiveness. A. 5, 2, 4, 3, 1 B. 1, 5, 2, 4, 3 C. 1, 2, 5, 4, 3 D. 5, 1, 4, 3, 2
D. 5, 1, 4, 3, 2 Establish unresponsiveness first. (The patient may have fallen and sustained a minor injury.) If the patient is unresponsive, get help and have someone initiate the code. Performing the chin lift or jaw thrust maneuver opens the airway. The nurse is then responsible for starting CPR. CPR should not be interrupted until the patient recovers or it is determined that heroic efforts have been exhausted. A crash cart should be at the site when the code team arrives; however, basic CPR can be effectively performed until the team arrives.
A client was brought to the ED due to an abdominal trauma caused by a motorcycle accident. During the assessment, the client complains of epigastric pain and back pain. Which of the following is true regarding the diagnosis of pancreatic injury? A. Redness and bruising may indicate the site of the injury in blunt trauma. B. The client is symptom-free during the early post-injury period. C. Signs of peritoneal irritation may indicate pancreatic injury. D. all of the above
D. All of the above Blunt injury resulting from vehicular accidents could cause pancreatic injury. Redness, bruising in the flank and severe peritoneal irritation are signs of a pancreatic injury. The client is usually pain-free during the early post-injury period, hence a comprehensive assessment and monitoring should be done.
A 15-year-old male client was sent to the emergency unit following a small laceration on the forehead. The client says that he can't move his legs. Upon assessment, respiratory rate of 20, strong pulses, and capillary refill time of less than 2 seconds. Which triage category would this client be assigned to? A. Black. B. Green. C. Red. D. Yellow.
D. Yellow. The client is possibly suffering from a spinal injury but otherwise, has a stable status and can communicate so the appropriate tag is YELLOW.
The wounded victim is unable to walk, respiratory rate is absent but when airway is repositioned breathing is noted. The wounded victim is assigned what tag color? A. Green B. Red C. Yellow D. Black
The answer is B: Red.
A catastrophic disaster has occurred 5 miles from the hospital you are working in. The hospital's disaster plan is activated and the wounded are brought to the hospital. You're helping triage the survivors. One of the wounded is able to walk around and has minor lacerations on the arms, hands, chest, and legs. You would place what color tag on this survivor? A. Red B. Yellow C. Green D. Black
The answer is C: Green tags are for patients who have MINOR injuries. If the patient can walk around they are tagged as green. Sometimes they are referred to as the "walking wounded"
You're working as a triage nurse during a disaster situation. Based on the triage color code tags placed on each of the wounded, which tag color represents the wounded who have the highest priority of being treated first? A. Green B. Yellow C. Red D. Black
The answer is C: Red. The red tag indicates the patient must be seen first because they have life-threatening injuries, but could survive if treated quickly. The patient is still alive but there is a severe alteration in their breathing, circulation, or mental status that requires immediate medical attention.
The wounded victim is unable to walk, respiratory rate is absent and when airway is repositioned breathing is still absent. The wounded victim is assigned what tag color? A. Green B. Red C. Yellow D. Black
The answer is D: Black.
While triaging the wounded from a disaster, you note that one of the wounded is not breathing, radial pulse is absent, capillary refill >2 seconds, and does not respond to your commands. What color tag is assigned? A. Green B. Red C. Yellow D. Black
The answer is D: Black. The black tag is placed on the wounded that are dying or have expired. The injuries are so severe that death is imminent. There is severe alteration or absence of breathing, circulation, and neuro status.
