TEST 17: Responding to Emergencies, Mass Casualties, and Disasters

Question 1

Emergencies
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.

Answer 1

Emergencies
1. 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.
CN: Physiological adaptation; CL: Analyze

Question 2

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:
3. Administer morphine sulfate IV push for the severe pain.
4. Call the physician to report the loss of the radial pulse.
5. Continue to assess the arm every hour for any additional changes.
6. Instruct the client to exercise his fingers and wrist.

Answer 2

2. 2. 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.
      CN: Safety and infection control; CL: Synthesize

Question 3

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?
4. Administer 1 L 0.9% normal saline IV.
5. Draw a complete blood count (CBC) with hematocrit and hemoglobin.
6. Obtain an abdominal x-ray.
7. Insert an indwelling urinary catheter.

Answer 3

3. 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.
   CN: Physiologic adaptation; CL: Analyze

Question 4

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

Answer 4

4. 1. 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.
      CN: Physiological adaptation; CL: Synthesize

Question 5

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

Answer 5

5.2. Assess the airway and breathing pattern.
1. Assess for urticaria.
4. Activate the rapid response team.
3. Notify the physician.
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.
CN: Reduction of risk potential; CL: Synthesize

Question 6

6. Proper hand placement for chest compressions during cardiopulmonary resuscitation (CPR) is
   essential to reduce the risk of which complication?
7. Gastrointestinal bleeding.
8. Myocardial infarction.
9. Emesis.
10. Rib fracture.

Answer 6

6. 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.
      CN: Physiological adaptation; CL: Apply

Question 7

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:
8. Early defibrillation in cases of atrial fibrillation.
9. Cardioversion in cases of atrial fibrillation.
10. Pacemaker placement.
11. Early defibrillation in cases of ventricular fibrillation.

Answer 7

7. 4. 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.
      CN: Reduction of risk potential; CL: Apply

Question 8

8. Indicate on the illustration below where the nurse would place the other electrode of the
   automated external defibrillator (AED) on a victim who has collapsed and does not have a pulse.

Answer 8

8. One electrode is placed to the right of the upper sternum just below the right clavicle. The other
   is placed, as shown, over the fifth or sixth intercostal space at the left anterior axillary line.
   CN: Reduction of risk potential; CL: Apply

Question 9

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.
10. Collect specimens for laboratory examination.
11. Assess vital signs.
12. Initiate support for the respiratory system.
13. Monitor fluid and electrolyte status.
14. Provide antiemetics, as prescribed.

Answer 9

9. 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.
   CN: Physiological adaptation; CL: Synthesize

Question 10

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?
11. The client was walking around in a daze.
12. The client has a lack of knowledge of what to do next.
13. The client is having delusions and is not in touch with reality.
14. The client is expressing helplessness and hopelessness and is a risk for suicide.

Answer 10

10. 4. 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.
       CN: Psychosocial integrity; CL: Analyze

Question 11

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?
12. Make sure suction equipment is set up bedside.
13. Draw blood for a phenytoin (Dilantin) level.
14. Assess the client’s vital signs.
15. Prepare the client for a head computed tomography (CT).

Answer 11

11. 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.
       CN: Physiological integrity; CL: Synthesize

Question 12

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 immunodeficiency virus (HIV) testing can only be
    completed when which of the following circumstances are present? Select all that apply.
13. An emergency medical provider has been exposed to the client’s blood or body fluids.
14. Testing is prescribed by a physician under emergency circumstances.
15. Testing is prescribed by a court, based on evidence that the client poses a threat to others.
16. Testing is done on blood collected anonymously in an epidemiologic survey.
17. When a health care provider who is taking care of a client who is suspected of having
    HIV/AIDS requests a blood test.

Answer 12

12. 1, 2, 3, 4. Upon a physician’s written prescription requesting an HIV test for a client, consentfor 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.
    CN: Safety and infection control; CL: Apply

Question 13

Mass Casualties
13. Several clients have come to the emergency department after a possible bioterrorist 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.

Answer 13

Mass Casualties
13. 1, 2, 3. When arsenic overexposure occurs, the symptoms include violent nausea, vomiting,
abdominal pain, skin irritation, severe diarrhea, laryngitis, and bronchitis. Dehydration can lead to
shock and death. After the acute phase, bone marrow depression, encephalopathy, and sensory
neuropathy occur. A persistent cough is not a sign of arsenic exposure.
CN: Physiological adaptation; CL: Analyze

Question 14

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

Answer 14

14. 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.
    CN: Management of care; CL: Analyze

Question 15

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.
16. The victim with chemical spills on both arms.
17. The victim with third-degree burns of both legs.
18. The victim with first-degree burns of both hands.
19. The victim in respiratory distress.
20. The victim who inhaled smoke.

Answer 15

15. 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.
    CN: Management of care; CL: Analyze

Question 16

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?
17. A woman who is 5 months pregnant with no apparent injuries.
18. A middle-aged man with no injuries who has rapid respirations and coughs.
19. A 10-year-old with a simple fracture of the humerus who is in severe pain.
20. A 20-year-old with first-degree burns on her hands and forearms.

Answer 16

16. 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.
       CN: Management of care; CL: Analyze

Question 17

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.
18. Cut around blood stains to remove clothing.
19. Place each item of clothing in a separate paper bag.
20. Hang wet clothing to dry.
21. Refrain from documenting client statements.
22. Place bullets in a sterile container.

Answer 17

17. 2, 3. Preserving forensic evidence is essential for investigative purposes following injuries
    that may be caused by criminal intent. The nurse should put each item of 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 clothing with such evidence as blood or body fluids. The
    nurse should document carefully the client’s description of the incident and use quotes around the
    client’s exact words where possible. The documentation will become a part of the client’s record and
    can be subpoenaed for subsequent investigation. The nurse should not handle bullets from the client
    because they are an important piece of forensic evidence.
    CN: Management of care; CL: Apply

Question 18

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.
19. Triage priority.
20. Identifying information when possible (such as name, age, and address).
21. Medications and treatments administered.
22. Presence of jewelry.5. Next of kin.

Answer 18

18. 1, 2, 3. Tracking victims of disasters is important for casualty planning and management. All
    victims should receive a tag, securely attached, that indicates the triage priority, any available
    identifying information, and what care, if any, has been given along with time and date. Tag
    information should be recorded in a disaster log and used to track victims and inform families. It is
    not necessary to document the presence of jewelry or next of kin.
    CN: Management of care; CL: Apply

Question 19

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

Answer 19

19. 2. The middle-aged woman is likely in shock. She is classified as a triage level I, requiring
       immediate care. The child with moderate trauma is classified as triage level III (urgent and should be
       treated within 30 minutes). The man with asthma and the man with the severe headache are classified
       as triage level II (emergent) and can be transported by ambulance and reach the hospital within 15
       minutes.
       CN: Management of care; CL: Analyze

Question 20

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.
21. Establish an airway with the jaw-thrust maneuver.
22. Immobilize the spine.
23. Logroll the victim to a side-lying position.
24. Elevate the feet 6 inches (15.2 cm).
25. Place a cervical collar around the neck.

Answer 20

20. 1, 2. The victim of 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 feet elevated. Both actions can cause additional injury to the spinal cord. Placing a cervical
    collar causes movement of the spinal column and should not be done as a first-aid measure.
    CN: Management of care; CL: Synthesize

Question 21

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?
22. Calling the nearest crisis response team.
23. Alerting the news media.
24. Notifying the hospital volunteer office.
25. Calling the school to inform teachers of the accident.

Answer 21

21. 1. The children and their families are at risk for experiencing a crisis. Disaster teams are
       available for crisis intervention in such emergencies. Usually the news media monitors emergency
       radio frequencies and most likely are aware of the accident already. Although volunteers may help in
       some ways, they are not responsible for crisis intervention. Calling the school might be done, but the
       emergency issues take precedence.
       CN: Psychosocial integrity; CL: Synthesize

Question 22

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.
23. A 75-year-old with a 2-inch (5.1-cm) laceration to the left forearm.
24. A 22-year-old with a 2-inch (5.1-cm) laceration to the left temple, slightly confused.
25. A 14-year-old with a 2-inch (5.1-cm) laceration to chin, history of asthma, respirations 26,
    audible wheezing.
26. A 22-year-old female, 36 weeks pregnant with contractions every 10 to 15 minutes

Answer 22

22.
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, lifesaving interventions for the wheezing and should
be seen first. The 22-year-old who is confused should be seen next to assess for head injury; the
location of the laceration could indicate a significant blunt force traumatic injury. The pregnant female
requires assessment but is not urgent unless other symptoms appear. The 75-year-old is nonurgent and
can wait safely for several hours.CN: Management of care; CL: Evaluate

Question 23

Disasters
23. A suspected outbreak of anthrax has been transmitted by skin exposure. A client is admitted 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.

Answer 23

Disasters
23. 1, 4. Anthrax is treated with antibiotics, and the client must continue the prescription for 60
days, even if symptoms do not persist. The client may have skin lesions at the point of contact, with
macula or papule formation; the eschar will fall off in 1 to 2 weeks. Clients with anthrax are not
contagious; the client does not need to follow isolation procedures at home. Anthrax from skin
exposure is not transmitted by respiratory contact, and the client does not need to wear a mask.
CN: Safety and infection control; CL: Synthesize

Question 24

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?
25. Enteric precautions.
26. Hand-washing precautions.
27. Reverse isolation.
28. Standard precautions.

Answer 24

24. 4. Transmission of SARS can be contained by following standard (universal) precautions,
       which include masks, gowns, eye protection, hand washing, and safe disposal of needles and sharps.
       The disease is spread by the respiratory, not enteric, route. Hand washing alone is not sufficient to
       prevent transmission. Reverse isolation (protection of the client) is not sufficient to prevent
       transmission.
       CN: Safety and infection control; CL: Synthesize

Question 25

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?
26. Contact isolation with double-gloving and shoe covers.
27. Respiratory isolation with positive pressure rooms.
28. Enteric precautions.
29. Reverse isolation.

Answer 25

25. 1. The nurse should institute treatment for hemorrhagic fever viruses, including contact
       isolation with double-gloving and shoe covers, strict hand hygiene, and protective eyewear. The
       nurse should start respiratory isolation with negative pressure 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.
       CN: Reduction of risk potential; CL: Synthesize

Question 26

26. Several clients come to the emergency department with suspected contamination by the Ebola
    virus. What should the nurse do? Select all that apply.
27. Call in extra staff to assist with the possibility of more clients with the same condition.
28. Isolate all the suspected clients in the emergency department in one area.
29. Call housekeeping for diluted household bleach.
30. Restrict visitors from the emergency department.
31. Quarantine all contacts

Answer 26

26. 2, 3, 4. The nurse should isolate all the suspected clients in the emergency department in one
    area and restrict visitors from the emergency department to minimize exposure to others. The nurse
    should also obtain diluted household bleach (1:100) to decontaminate areas suspected of coming in
    contact with the virus. There is no indication at this time that extra staff is needed, so the nurse should
    not call in extra staff, to minimize exposure to health care workers. It is not necessary to quarantine
    contacts until a diagnosis is confirmed. In addition, it is the role of the public health officer to issue
    the quarantine if needed.
    CN: Safety and infection control; CL: Synthesize

Question 27

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.
28. Violent vomiting.
29. Severe diarrhea.
30. Abdominal pain.
31. Sensory neuropathy.
32. Persistent cough

Answer 27

27. 1, 2, 3. 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. After the acute phase, bone marrow depression, encephalopathy, and sensory
    neuropathy occur.
    CN: Physiological adaptation; CL: Analyze

Question 28

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?
29. Apply oxygen at 3 L per nasal cannula.
30. Remove their clothing.
31. Begin decontamination shower.
32. Isolate the clients.

Answer 28

28. 4. Safety of the staff and others is the first priority. By isolating the clients, this reduces the
       chance of contaminating others (secondary contamination). Vital signs can be obtained when it is safe
       —after protecting staff, patients, and visitors from secondary contamination. Oxygen is not indicated
       for any of the listed symptoms. Removing clothing is important to prevent further exposure to the
       client, but must be done in a safe manner to prevent secondary contamination to others. The clients
       can remove their own clothes and place them in plastic bags. After the safety of the staff and others is
       addressed, AND the facility is prepared and properly trained staff is ready, the clients can be given adecontamination shower. If the staff 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.
       CN: Management of care; CL: Synthesize

Question 29

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.
30. A 10-year-old male with crushing chest wound, tachypnea with labored breathing,
    unconscious, impaled object in forehead.
31. 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.
32. 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.
33. 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.

Answer 29

29. 2, 3. The client with crushing chest pain has an acute cardiac condition and can have a
    successful outcome if immediate interventions are initiated. The client with the open fracture could be
    stabilized and is not a significant factor in triage in a mass casualty incident. The client with a
    displaced femur fracture can also be classified as immediate because the fracture can impair
    circulation. There are also signs of shock and severe pain. All conditions can improve with
    interventions. In a mass casualty incident, the goal is to do the greatest good for the greatest number—
    which sometimes means that limited resources are not allocated to the very critically injured that have
    a very low probability of survival. The other two clients are categorized as “black”/expectant
    because of their critical injuries and the unavailability of advance trauma care.
    CN: Management of care; CL: Analyze

Question 30

30. The nurse is assessing the client (see photo below) who has recently returned from a 2-month
    mission in Africa. What type of respiratory protection is appropriate for the staff?
31. N95 particulate respirator.
32. Double-layered surgical mask.
33. Surgical mask with eye shield.
34. No respiratory protection is needed.

Answer 30

30. 1. Any type of blistering lesion, such as smallpox, requires extreme care to prevent exposure.
       Transmission-based precautions for smallpox includes airborne, droplet, and contact precautions.
       The N95 mask filters at least 95% of airborne particles. To prevent exposure through the respiratory
       tract, the N95 mask must be fitted and worn properly.
       CN: Safety and infection control; CL: Synthesize

Question 31

Managing Care Quality and Safety
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.

Answer 31

Managing Care Quality and Safety
31. 2, 4. The UAP can cover the body and transport 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 contacted. The health care provider should be the one to
notify the family. The nurse should be the one to notify the chaplain.
CN: Management of care; CL: Synthesize

Question 32

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?
33. Contact the pharmacist immediately to check the prescription and the barcode label for
    accuracy.
34. Administer the medication now, knowing the medication is labeled and the client is identified.
35. Report the problem to the information technology team to have the barcode system
    recalibrated.
36. Ask another nurse to verify the medication and the client so the medication can be given now.

Answer 32

32. 1. The nurse should contact the pharmacist first to be sure the medication is labeled for
       administration to this client. The nurse should not administer the drug until all safety precautions have
       been observed; the nurse should also not ask another nurse to verify the medication or client. Later, if
       the problem cannot be resolved with relabeling the medication, the nurse or pharmacist can contact
       the information technology team to check the barcode system.
       CN: Safety and infection control; CL: Synthesize

Question 33

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.
34. Vehicle/s description.
35. Current location of parties involved.
36. Names and phone numbers of parties involved.
37. Relationship to hospitalized client.
38. Tone of voice of each party involved.

Answer 33

33. 1, 2. All suspicious individuals or activities should be reported as soon as possible to the
    security department. When reporting an incident, nurses/employees should provide the following: (a)
    type of incident; (b) persons involved/physical description; (c) vehicles involved and description; (d)
    date and time the incident occurred; (e) location where the incident occurred; (f) weapons involved;
    and (g) current location of parties involved. All reports of threats, actual episodes of violence, or
    suspicious individuals or activities must be investigated.
    CN: Safety and infection control; CL: Synthesize

Question 34

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.
35. When a medication prescription or critical laboratory result is received verbally or over the
    telephone.
36. When any verbal or phone prescription is received.
37. Whenever a written prescription or printed critical test result is received.
38. When the unit secretary takes a phone prescription.
39. When the agency uses computerized health care records.

Answer 34

34. 1, 2. A goal of client safety is to improve the effectiveness of communication among
    caregivers. For verbal or telephone prescriptions, or for telephone reporting of critical test results,one must verify the complete prescription or test result by having the individual receiving the
    information record “read-back” the complete prescription or test result. The Unit Secretary is not a
    licensed health care professional who has a Scope of Practice or the authority to receive
    prescriptions or results. The type of charting system used by the health care agency is not a factor in
    using “read-back” prescriptions.
    CN: Safety and infection control; CL: Synthesize