Unit S-Emergency and Disaster Preparedness

Question 1

An emergency department nurse assesses a client who has been raped. With which health care team member would the nurse collaborate when planning this client’s care?

a. Primary health care provider
b. Case manager
c. Forensic nurse examiner
d. Psychiatric crisis nurse

Answer 1

ANS: C
All other members of the health care team listed may be used in the management of this client’s care. However, the forensic nurse examiner is educated to obtain client histories and collect evidence dealing with the assault, and can offer the counseling and follow-up needed when dealing with the victim of an assault.

Question 2

An emergency department nurse is triaging victims of a multi-casualty event. Which client would receive care first?

a. A 30-year-old distraught mother holding her crying child
b. A 65-year-old conscious male with a head laceration
c. A 26-year-old male who has pale, cool, clammy skin
d. A 48 year old with a simple fracture of the lower leg

Answer 2

ANS: C
The client with pale, cool, clammy skin may be in shock and needs immediate medical attention. The mother does not have injuries and so would be the lowest priority. The other two people need medical attention soon, but not at the expense of a person in shock.

Question 3

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?

a. Apply oxygen via nasal cannula.
b. Administer intravenous 0.9% saline solution.
c. Transfer the client to a negative-pressure room.
d. Obtain a sputum culture and sensitivity.

Answer 3

ANS: C
A client with signs and symptoms of tuberculosis or other airborne pathogens would be placed in a negative-pressure room to prevent contamination of staff, clients, and family members in the crowded emergency department. The client may or may not need oxygen or an IV. A sputum culture would be obtained but is not the priority.

Question 4

A nurse is triaging clients in the emergency department (ED). Which client would the nurse prioritize to receive care first?
a. A 22 year old with a painful and swollen right wrist
b. A 45 year old reporting chest pain and diaphoresis
c. A 60 year old reporting difficulty swallowing and nausea
d. An 81 year old, respiratory rate 28 breaths/min and temperature of 101° F (38.8°
C)

Answer 4

ANS: B
A client experiencing chest pain and diaphoresis would be classified as emergent and would be triaged immediately to a treatment room in the ED. The other clients are more stable.

Question 5

A nurse is evaluating levels and functions of trauma centers. Which function is appropriately paired with the level of the trauma center?
a. Level I—located within remote areas and provides advanced life support within
resource capabilities
b. Level II—located within community hospitals and provides care to most injured
clients
c. Level III—located in rural communities and provides only basic care to clients
d. Level IV—located in large teaching hospitals and provides a full continuum of
trauma care for all clients

Answer 5

ANS:B
Level I trauma centers are usually located in large teaching hospital systems and provide a full continuum of trauma care for all clients. Both Level II and Level III facilities are usually located in community hospitals. These trauma centers provide care for most clients and transport to Level I centers when client needs exceed resource capabilities. Level IV trauma centers are usually located in rural and remote areas. These centers provide basic care, stabilization, and advanced life support while transfer arrangements to higher level trauma centers are made.

Question 6

Emergency medical technicians arrive at the emergency department with an unresponsive client who has an oxygen mask in place. Which action would the nurse take first?

a. Assess that the client is breathing adequately.
b. Insert a large-bore intravenous line.
c. Place the client on a cardiac monitor.
d. Assess for the best neurologic response

Answer 6

ANS: A
After establishing an airway, the highest priority intervention in the primary survey is to establish that the client is breathing adequately. Even though this client has an oxygen mask on, he or she may not be breathing, or may be breathing inadequately with the device in place. Inserting an IV line and placing the client on a monitor would come after ensuring a patent airway and effective breathing.

Question 7

A trauma client with multiple open wounds is brought to the emergency department in cardiac arrest. Which action would the nurse take prior to providing advanced cardiac life support?

a. Contact the on-call orthopedic surgeon.
b. Don personal protective equipment.
c. Notify the Rapid Response Team.
d. Obtain a complete history from the paramedic

Answer 7

ANS: B
Nurses must recognize and plan for a high risk of contamination with blood and body fluids when engaging in trauma resuscitation. Standard Precautions would be taken in all resuscitation situations and at other times when exposure to blood and body fluids is likely. Proper attire consists of an impervious cover gown, gloves, eye protection, a facemask, a surgical cap, and shoe covers. It is not known if this client has orthopedic injuries. The Rapid Response Team is not needed in the ED. A complete history is needed but the staff’s protection comes first.

Question 8

A nurse is triaging clients in the emergency department. Which client would be considered “urgent”?

a. A 20-year-old female with a chest stab wound and tachycardia
b. A 45-year-old homeless man with a skin rash and sore throat
c. A 75-year-old female with a cough and a temperature of 102° F (38.9° C)
d. A 50-year-old male with new-onset confusion and slurred speech

Answer 8

ANS: C
A client with a cough and a temperature of 102° F (38.9° C) is urgent. This client is at risk for deterioration and needs to be seen quickly, but is not in an immediately life-threatening situation. The client with a chest stab wound and tachycardia and the client with new-onset confusion and slurred speech would be triaged as emergent. The client with a skin rash and a sore throat is not at risk for deterioration and would be triaged as nonurgent.

Question 9

An emergency department nurse is caring for a client who has died from a suspected homicide. Which action does the nurse take?

a. Remove all tubes and wires in preparation for the medical examiner.
b. Limit the number of visitors to minimize the family’s trauma.
c. Consult the bereavement committee to follow up with the grieving family.
d. Communicate the client’s death to the family in a simple and concrete manner.

Answer 9

ANS: D
When dealing with clients and families in crisis, communicate in a simple and concrete manner to minimize confusion.GTRuAbeDsEmSuLstArBem.aCinOiMn place for the medical examiner. Family would be allowed to view the body. Offering to call for additional family support during the crisis is suggested. The bereavement committee would be consulted, but this is not the priority at this time

Question 10

An emergency department (ED) case manager is consulted for a client who is homeless. Which intervention would the case manager provide?

a. Communicate client needs and restrictions to support staff.
b. Prescribe low-cost antibiotics to treat community-acquired infection.
c. Provide referrals to subsidized community-based health clinics.
d. Offer counseling for substance abuse and mental health disorders.

Answer 10

ANS: C
Case management interventions include facilitating referrals to primary care providers who are accepting new clients or to subsidized community-based health clinics for clients or families in need of routine services. The ED nurse is accountable for communicating pertinent staff considerations, client needs, and restrictions to support staff (e.g., physical limitations, Isolation Precautions) to ensure that ongoing client and staff safety issues are addressed. The ED provider prescribes medications and treatments. The psychiatric nurse team evaluates clients with emotional behaviors or mental illness and facilitates the follow-up treatment plan, including possible admission to an appropriate psychiatric facility.

Question 11

A nurse is triaging clients in the emergency department. Which client would the nurse classify as “nonurgent?”

a. A 44 year old with chest pain and diaphoresis
b. A 50 year old with chest trauma and absent breath sounds
c. A 62 year old with a simple fracture of the left arm
d. A 79 year old with a tempeGraRtuAreDoEfS1L04A°BF.(C40O.0M° C)

Answer 11

ANS: C
A client in a nonurgent category can tolerate waiting several hours for health care services without a significant risk of clinical deterioration. The client with a simple arm fracture and palpable radial pulses is currently stable, is not at significant risk of clinical deterioration, and would be considered nonurgent. The client with chest pain and diaphoresis and the client with chest trauma are emergent owing to the potential for clinical deterioration and would be seen immediately. The client with a high fever may be stable now but also has a risk of deterioration.

Question 12

What is the primary goal of a triage system used by the nurse with clients presenting to the emergency department?

a. Determine the acuity of the client’s condition to determine priority of care.
b. Assess the status of the airway, breathing, circulation, or presence of deficits.
c. Determine whether the client is responsive enough to provide needed information.
d. Evaluate the emergency department’s resources to adequately treat the patient.

Answer 12

ANS:A
ED triage is an organized system for sorting and classifying clients into priority levels depending on illness or injury severity. The primary goal of the triage system is to facilitate the ED nurse’s ability to prioritize care according to the acuity of the patient, having the clients with the more severe illness or injury seen first. Airway, breathing, and circulation are part of the primary survey. Determining responsiveness is done during the disability phase of the primary survey and is not the primary goal. Evaluating the ED’s resources is also not a goal of triage.

Question 13

An elderly client who has fallen from a roof is transported to the emergency department by ambulance. The client was unconscious at the scene but is conscious on arrival and is triaged as urgent. What is the priority assessment the nurse includes during the primary survey of the patient?

a. A full set of vital signs
b. Cardiac rhythm
c. Neurologic status
d. Client history

Answer 13

ANS: C
The primary survey for a trauma client organizes the approach to the client so that life-threatening injuries are rapidly identified and managed. Injuries from this type of fall have a high risk for cervical spine injuries. In addition, with the loss of consciousness at the scene the client would be at risk for head trauma. A full set of vital signs is obtained as part of the
secondary survey. The cardiac rhythm is important but not specifically related to this client’s
presentation. Client history would be obtained as able.
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Question 14

A nurse is caring for clients in a busy emergency department. What actions would the nurse take to ensure client and staff safety? (Select all that apply.)
a. Leave the stretcher in the lowest position with rails down so that the client can
access the bathroom.
b. Use two identifiers before each intervention and before mediation administration.
c. Attempt de-escalation strategies for clients who demonstrate aggressive behaviors.
d. Search the belongings of clients with altered mental status to gain essential
medical information.
e. Use facility policy identification procedures for “Jane/John Doe” clients.
f. Check clients for a medical alert bracelets or necklaces.
g. Avoid using Security personnel to prevent escalation of client behaviors.

Answer 14

ANS: B,C,D,E,F
Best practices for client and staff safety in the emergency department include leaving beds in the lowest position with side rails up, using two unique identifiers for medications and procedures, using de-escalation strategies for clients or visitors showing hostile or aggressive behaviors, searching the belongings of confused clients for medical information, using facility identification systems for Jane/John Doe clients, observing for medical alert jewelry, and using security staff as needed.

Question 15

An emergency department nurse is caring for a trauma patient. Which interventions does the nurse perform during the primary survey? (Select all that apply.)

a. Foley catheterization
b. Needle decompression
c. Initiating IV fluids
d. Splinting open fractures
e. Endotracheal intubation
f. Removing wet clothing
g. Laceration repair

Answer 15

The primary survey for a trauma client organizes the approach to the client so that life-threatening injuries are rapidly identified and managed. The primary survey is based on the standard mnemonic ABC, with an added D and E: Airway and cervical spinal motion restriction; Breathing; Circulation; Disability; and Exposure. After the completion of primary diagnostic and laboratory studies, and the insertion of gastric and urinary tubes, the secondary survey (a complete head-to-toe assessment) can be carried out.

Question 16

The complex care provided during an emergency requires interprofessional collaboration. Which team members are paired with the correct responsibilities? (Select all that apply.)
a. Psychiatric crisis nurse—interacts with clients and families when sudden illness,
serious injury, or death of a loved one may cause a crisis
b. Forensic nurse examiner—performs rapid assessments to ensure that clients with
the highest acuity receive the quickest evaluation, treatment, and prioritization of
resources
c. Triage nurse—provides basic life support interventions such as oxygen, basic
wound care, splinting, spinal motion restriction, and monitoring of vital signs
d. Emergency medical technician—obtains client histories, collects evidence, and
offers counseling and follow up care for victims of rape, child abuse, and domestic
violence
e. Paramedic—provides prehospital advanced life support, including cardiac
monitoring, advanced airway management, and medication administration

Answer 16

ANS: A,E
The psychiatric crisis nurse evaluates clients with emotional behaviors or mental illness and facilitates follow-up treatment plans. The psychiatric crisis nurse also works with clients and families when experiencing a crisis. Paramedics are advanced life support providers who can perform advanced techniques that may include cardiac monitoring, advanced airway management and intubation, establishing IV access, and administering drugs en route to the emergency department. The forensic nurse examiner is trained to recognize evidence of abuse and to intervene on the client’s behalf. The forensic nurse examiner will obtain client histories, collect evidence, and offer counseling and follow up care for victims of rape, child abuse, and domestic violence. The triage nurse performs rapid assessments to ensure that clients with the highest acuity receive the quickest evaluation, treatment, and prioritization of resources. The emergency medical technician is usually the first caregiver and provides basic life support and transportation to the emergency department.

Question 17

A nurse prepares to discharge an older adult client home from the emergency department (ED). What actions does the nurse take to prevent future ED visits? (Select all that apply.)

a. Provide medical supplies to the family.
b. Consult a home health agency.
c. Encourage participation in community activities.
d. Screen for depression and suicide.
e. Complete a functional assessment.

Answer 17

ANS: D,E
Due to the high rate of suicide among older adults, a nurse would assess all older adults for depression and suicide. The nurse would also screen older adults for functional assessment, cognitive assessment, and risk for falls to prevent future ED visits

Question 18

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?

a. Encourage the client to drink cool water or sports drinks.
b. Start an intravenous line and infuse 0.9% saline solution.
c. Administer acetaminophen (Tylenol) 650 mg orally.
d. Encourage rest and reassess in 15 minutes.

Answer 18

ANS: B
The client demonstrates signs of heat stroke. This is a medical emergency and priority care includes oxygen therapy, IV infusion with 0.9% saline solution, insertion of a urinary catheter, and aggressive interventions to cool the patient, including external cooling and internal cooling methods. Oral hydration would not be appropriate for a client who has symptoms of heat stroke because oral fluids would not provide necessary rapid rehydration, and the confused client would be at risk for aspiration. Acetaminophen would not decrease this patient’s temperature or improve the patient’s symptoms. The client needs immediate medical treatment; therefore, rest and reassessing in 15 minutes are inappropriate

Question 19

While at a public park, a nurse encounters a person immediately after a bee sting. The person’s lips are swollen, and wheezes are audible. What action would the nurse take first?

a. Elevate the site and notify the person’s next of kin.
b. Remove the stinger with tweezers and encourage rest.
c. Administer diphenhydramine and apply ice.
d. Administer an epinephrine autoinjector and call 911.

Answer 19

ANS: D
The client’s swollen lips indicate that anaphylaxis may be developing, and this is a medical emergency. The nurse would call 911 would immediately, and the client transported to the emergency department as quickly as possible. If an EpiPen is available, it would be administered at the first sign of an anaphylactic reaction. The other answers do not provide adequate interventions to treat airway obstruction due to anaphylaxis, although the nurse would remove the stinger as soon as possible after administering the autoinjector.

Question 20

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?

a. Reposition the client into a prone position.
b. Administer warmed intravenous fluids to the client.
c. Wrap the client’s extremities in warm blankets.
d. Initiate extracorporeal rewarming via hemodialysis

Answer 20

ANS: B
Moderate hypothermia manifests with muscle weakness, increased loss of coordination, acute confusion, apathy, incoherence, stupor, and impaired clotting. Moderate hypothermia is treated by core rewarming methods, which include administration of warm IV fluids; heated oxygen; and heated peritoneal, pleural, gastric, or bladder lavage. The client’s trunk would be warmed prior to the extremities to prevent peripheral vasodilation. Extracorporeal warming with cardiopulmonary bypass or hemodialysis is a treatment for severe hypothermia.

Question 21

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?

a. Administer dexamethasone.
b. Complete a mini mental state examination.
c. Prepare the client for computed tomography of the brain.
d. Request a psychiatric consult.

Answer 21

ANS: A
The client is exhibiting signs of mountain sickness and high-altitude cerebral edema (HACE). Dexamethasone reduces cerebral edema by acting as an anti-inflammatory in the central nervous system. The other interventions will not specifically treat HACE, although a thorough mental status exam would be pGerRfoArmDeEdS

Question 22

An emergency department nurse assesses a client admitted after a lightning strike. The client is awake but somewhat confused. Which assessment would the nurse complete first?

a. Electrocardiogram (ECG)
b. Wound inspection
c. Creatinine kinase
d. Computed tomography of head

Answer 22

ANS: A
Clients who survive a lightning strike can have serious myocardial injury, which can be manifested by ECG and myocardial perfusion abnormalities. The nurse would prioritize the ECG over the other assessments which would be completed later.

Question 23

A nurse teaches a community health class about water safety. Which statement by a participant indicates that additional teaching is needed?

a. “I can go swimming all by myself because I am a certified lifeguard.”
b. “I cannot leave my toddler alone in the bathtub for even a minute.”
c. “I will appoint one adult to supervise the pool at all times during a party.”
d. “I will make sure that there is a phone near my pool in case of an emergency.”

Answer 23

ANS: A
People would never swim alone, regardless of lifeguard status. The other statements indicate good understanding of the teaching.

Question 24

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?

a. Administer intravenous morphine.
b. Wrap the limb with a compression dressing.
c. Massage the frostbitten areas.
d. Assess the limb for compartment syndrome.

Answer 24

ANS: A
Rapid rewarming in a water bath is recommended for all instances of partial-thickness and full-thickness frostbite. Patients experience severe pain during the rewarming process and nurses would administer intravenous analgesics.

Question 25

A nurse assesses a client recently bitten by a coral snake. Which assessment would the nurse complete first?

a. Unilateral peripheral swelling
b. Clotting times
c. Cardiopulmonary status
d. Electrocardiogram rhythm

Answer 25

ANS: C
Signs and symptoms of coral snake envenomation are the result of its neurotoxic properties. The physiologic effect is to block neurotransmission, which produces ascending paralysis, reduced perception of pain, and, ultimately, respiratory paralysis. The nurse would monitor for respiratory rate and depth. Severe swelling and clotting problems do not occur with coral snakes but do occur with pit viper snakes. Electrocardiogram rhythm is not affected by neurotoxins.

Question 26

A nurse plans care for a client admitted with a snakebite to the right leg. With whom would the nurse collaborate?

a. The facility’s neurologist
b. The poison control center
c. The physical therapy department
d. A herpetologist (snake specialist)

Answer 26

ANS: B
For the client with a snakebite, the nurse would contact the regional poison control center immediately for specific advice on antivenom administration and client managemen

Question 27

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?

a. Deliver rescue breaths.
b. Wrap the client in dry blankets.
c. Assess for signs of bleeding.
d. Check for a carotid pulse.

Answer 27

ANS: A
In this emergency situation, the nurse immediately initiates airway clearance and ventilator support measures, including delivering rescue breaths.

Question 28

A nurse assesses a client admitted with a brown recluse spider bite. Which assessment does the nurse perform to identify complications of this bite?

a. Ask the client about pruritus at the bite site.
b. Inspect the bite site for a bluish purple vesicle.
c. Assess the extremity for redness and swelling.
d. Monitor the client’s temperature every 4 hours.

Answer 28

ANS: D
Fever and chills indicate systemic toxicity, which can lead to hemolytic anemia, thrombocytopenia, DIC, and death. Assessing for a fever would indicate this complication. All other symptoms are normal for a brown recluse bite and would be assessed, but they do not provide information about complications from the bite.

Question 29

A primary health care provider prescribes diazepam to a client who was bitten by a black widow spider. The client asks, “What is this medication for?” How does the nurse respond?

a. “This medication is an antivenom for this type of bite.”
b. “It will relieve your muscle rigidity and spasms.”
c. “It prevents respiratory difficulty from excessive secretions.”
d. “This medication will prevent respiratory failure.”

Answer 29

ANS: B
Black widow spider venom can produce muscle rigidity and spasms, which are treated with the muscle relaxant, diazepam. It does not prevent respiratory difficulty or failure nor is it antivenom.

Question 30

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?
a. “If my climbing partner can’t think straight, we should descend to a lower
altitude.”
b. “I will ask my primary health care provider about medications to help prevent
acute mountain sickness.”
c. “My partner and I will plan to sleep at a higher elevation to acclimate more
quickly.”
d. “I will drink plenty of fluids to stay hydrated while on the mountain.”

Answer 30

ANS: C
Teaching to prevent altitude-related illness would include descending when symptoms start, staying hydrated, and taking acetazolamide, which is commonly used to prevent and treat acute mountain sickness. The nurse would teach the client to sleep at a lower elevation.

Question 31

A client admitted to the emergency department following a lightning strike. What is the priority assessment the nurse focuses on?

a. Cardiopulmonary
b. Integumentary
c. Peripheral vascular
d. Renal

Answer 31

ANS: A
Lightning strikes can profoundly affect the cardiopulmonary and the central nervous system
as a serious cardiac and/or respiratory arrest. The nurse would be alert for reports of chest pain and would watch for dysrhythmias on the cardiac monitor. As impairment of the respiratory center can also be affected, the nurse would assess the respiratory system second.

Question 32

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?

a. Administer acetazolamide.
b. Administer oxygen via a nonrebreather mask.
c. Complete a thorough pulmonary assessment.
d. Obtain arterial blood gas (ABG) specimen for analysis.

Answer 32

ANS: B
The client is exhibiting signs of AMS with high-altitude pulmonary edema (HAPE). Cyanosis indicates hypoxia and must be treated immediately. A complete pulmonary assessment and ABG analysis are indicated but the priority is oxygen administration. Acetazolamide is used to prevent AMS

Question 33

A nurse is teaching a wilderness survival class. Which statements would the nurse include about the prevention of hypothermia and frostbite? (Select all that apply.)

a. “Wear synthetic clothing instead of cotton to keep your skin dry.”
b. “Drink plenty of fluids. Brandy can be used to keep your body warm.”
c. “Remove your hat when exercising to prevent overheating.”
d. “Wear sunglasses to protect skin and eyes from harmful rays.”
e. “Know your physical limits. Come in out of the cold when limits are reached.”
f. “Change your gloves and socks if they become wet.”

Answer 33

ANS: A,D,E,F
To prevent hypothermia and frostbite, the nurse would teach patients to wear synthetic
clothing (which moves moisture away from the body and dries quickly), layer clothing, and a
hat, facemask, sunscreen, and sunglasses. The client would also be taught to drink plenty of
fluids, but to avoid alcohol when participating in winter activities. Clients need to know their
physical limits and come in out of the cold when these limits have been reached. Wet clothing
contributes to heat loss so clients would be taught to change any clothing that becomes wet.

Question 34

A nurse teaches a client who has severe allergies ways to prevent insect bites. Which statements does the nurse include in this client’s teaching? (Select all that apply.)

a. “Consult an exterminator to control bugs in and around your home.”
b. “Do not swat at insects or wasps.”
c. “Wear sandals whenever you go outside.”
d. “Keep your prescribed epinephrine autoinjector in a bedside drawer.”
e. “Use screens in your windows and doors to prevent flying insects from entering.”
f. “Identify and remove potential nesting sites in your yard.”

Answer 34

ANS: A,B,E,F
To prevent arthropod bites and stings, patients should wear protective clothing, cover garbage cans, use screens in windows and doors, inspect clothing and shoes before putting them on, consult an exterminator, remove nests, avoid swatting at insects, and carry a prescription epinephrine autoinjector at all times if they are known to be allergic to bee or wasp stings. Shoes are needed when working in areas known or suspected to harbor arthropods, but sandals will not protect the feet. Removing nesting sites may help eliminate the population.

Question 35

A nurse is providing health education at a community center. Which instructions does the nurse include in teaching about prevention of lightning injuries during a storm? (Select all that apply.)

a. Seek shelter inside a building or vehicle.
b. Hide under a tall tree.
c. Do not take a bath or shower.
d. Turn off the television.
e. Remove all body piercings.
f. Put down golf clubs or gardening tools.

Answer 35

ANS: A,C,D,F
When thunder is heard, individuals should seek shelter in a safe area such as a building or an enclosed vehicle. Electrical equipment such as TVs and stereos should be turned off. Stay away from plumbing, water, and metal objects such as golf clubs or gardening tools. Do not stand under an isolated tall tree or a structure such as a flagpole. Body piercings will not increase a person’s chances of being struck by lightning.

Question 36

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? (Select all that apply.)

a. Administer oxygen via mask or nasal cannula.
b. Administer ibuprofen, an antipyretic medication.c. Apply cooling techniques until core body temperature is less than 101° F (38.3° C).
d. Infuse 0.9% sodium chloride via a large-bore intravenous cannula.
e. Obtain baseline serum electrolytes and cardiac enzymes.
f. Insert an indwelling urinary catheter for urine output measurements.

Answer 36

ANS: A,D,E
Heat stroke is a medical emergency. Oxygen therapy and intravenous fluids would be provided, and baseline laboratory tests would be performed as quickly as possible. Urinary output is measured via an indwelling urinary catheter. The client would be cooled until core body temperature is reduced to 102° F (38.9° C). Antipyretics would not be administered.

Question 37

A nurse is in charge of a first-aid tent at an all-day outdoor sports event on a hot and humid day. A participant comes to the tent reporting a headache, weakness, and nausea. What actions would the nurse take? (Select all that apply.)

a. Have the client lie down in a cool place.
b. Force fluids with large quantities of plain water.
c. Administer acetaminophen and send home.
d. Apply cold packs to neck, arm pits, and groin.
e. Encourage drinking a sports drink.
f. Remove all clothing and cover with a towel.

Answer 37

ANS: A,D,E
Heat exhaustion manifests as flGuRlikAeDsEymSpLtoAmBs.wCiOthMheadache, weakness, nausea, and/or vomiting. Treatment includes stopping the activity, moving to a cool place, and using cooling measures such as cold packs, cool water soaks, or fanning while spraying cool water on skin. Sodium deficits may occur from drinking plain water, so sports drinks or an oral rehydration therapy solution would be provided. The nurse would remove constrictive clothing only.

Question 38

Which assessment findings would indicate to the nurse that a client has suffered from a heat stroke? (Select all that apply.)

a. Confusion and bizarre behavior
b. Headache and fatigue
c. Hypotension
d. Presence of perspiration
e. Tachycardia and tachypnea
f. Body temperature more than 104° F (40° C)

Answer 38

ANS: A,C,E,F
Signs and symptoms of heat stroke include as elevated body temperature (above 104° F [40° C]), mental status changes such as confusion and decreasing level of consciousness, hypotension, tachycardia, and tachypnea. Perspiration is an inconsistent finding.

Question 39

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)? (Select all that apply.)

a. Ataxia
b. Confusion
c. Crackles in both lung fields
d. Decreased level of consciousness
e. Persistent dry cough
f. Reports “feeling hung over”

Answer 39

ANS: C,E
Signs and symptoms of high-altitude pulmonary edema (HAPE) include poor exercise tolerance, prolonged recovery time after exertion, fatigue, and weakness that progresses to a persistent dry cough and cyanosis of lips and nail beds. Crackles may be auscultated in one or both lung fields. A late sign of HAPE is pink, frothy sputum. Ataxia and confusion or decreased level of consciousness are seen in HACE—high-altitude cerebral edema. Acute mountain sickness produces a syndrome similar to an alcohol-induced hangover.

Question 40

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.)
a. Bilateral crackles
b. Bradycardia
c. Cyanosis of the lips
d. Hypotension
e. Flushed, diaphoretic skin
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Answer 40

ANS: A,B,C,D
Drowning victims will exhibit signs of pulmonary edema which includes crackles in one or both lungs, persistent dry cough, and cyanosis of the lips and/or nail beds. The diving reflex as a response to asphyxia produces bradycardia, signs of decreased cardiac output with hypotension, and vasoconstriction of vessels in the intestine, skeletal muscles, and kidneys.

Question 41

The nurse is teaching participants in a family-oriented community center ways to prevent their older relatives and friends from getting heat-related illnesses. What information does the nurse include? (Select all that apply.)

a. Use sunscreen with an SPF of at least 15 when outdoors.
b. Take cool baths or showers after outdoor activities.
c. Check on the older adult daily in hot weather.
d. Drink plenty of liquids throughout the day.e. Wear light-colored, snugly-fitting clothing to wick sweat away

Answer 41

ANS: B,C,D
To best prevent heat-related illnesses, the nurse would teach individuals to use sunscreen with at least an SPF of 30 for both UVA and UVB rays, to shower or bathe in cool water after being outdoors to reduce body heat, to remain hydrated, and to wear light-colored, loose-fitting clothes. Families and friends should check older adults at least twice a day during a heat wave; however, this may not prevent heat-related illness but could catch it quickly and limit its severity.

Question 42

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?

a. Provide water and healthy snacks for energy throughout the event.
b. Schedule 16-hour shifts to allow for greater rest between shifts.
c. Encourage counseling upon deactivation of the emergency response plan.
d. Assign staff to different roles and units within the medical facility.

Answer 42

ANS: A
To prevent staff posttraumatic stress disorder during a mass casualty event, the nurses would use available counseling, encourage and support co-workers, monitor each other’s stress level and performance, take breaks when needed, talk about feelings with staff and managers, and drink plenty of water and eat healthy snacks for energy. Nurses would also keep in touch with family, friends, and significant others, and not work for more than 12 hours/day. Encouraging counseling upon deactivation of the plan, or after the emergency response is over, does not prevent stress during the casualty event. Assigning staff to unfamiliar roles or units may increase situational stress and is not an approach to prevent posttraumatic stress disorder. These actions also help mitigate PTSD after the event.

Question 43

A client who is hospitalized with burns after losing the family home in a fire becomes angry and screams at a nurse when dinner is served late. How would the nurse respond?

a. “Do you need something for pain right now?”
b. “Please stop yelling. I brought dinner as soon as I could.”
c. “I suggest that you get control of yourself.”
d. “You seem upset. I have time to talk if you’d like.”

Answer 43

ANS: D
Clients would be allowed to ventilate their feelings of anger and despair after a catastrophic event. The nurse establishes rapport through active listening and honest communication and by recognizing cues that the client wishes to talk. Asking whether the client is in pain as the first response closes the door to open communication and limits the client’s options. Simply telling the client to stop yelling and to gain control does nothing to promote therapeutic communication.

Question 44

A nurse is field-triaging clients after an industrial accident. Which client condition would the nurse triage with a red tag?

a. Dislocated right hip and an open fracture of the right lower leg
b. Large contusion to the forehead and a bloody nose
c. Closed fracture of the right clavicle and arm numbness
d. Multiple fractured ribs and shortness of breath

Answer 44

ANS: D
Clients who have an immediate threat to life are given the highest priority, are placed in the emergent or class I category, and are given a red triage tag. The client with multiple rib fractures and shortness of breath has a threat to oxygenation and is the most critical. The client with the hip and leg problem and the client with the clavicle fracture would be classified as class II (urgent, yellow tag); these major but stable injuries can wait for 30 minutes to 2 hours for definitive care. The client with facial wounds would be considered the “walking wounded” and classified as nonurgent (class III, green tag).

Question 45

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?
a. Ask nursing staff to discharge clients from the medical-surgical units in order to
make room for critically injured victims.
b. Call additional medical-surgical and critical care nursing staff to come to the
hospital to assist when victims are brought in.
c. Inform the incident commander at the mass casualty scene about how many
victims may be handled by the ED.
d. 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.

Answer 45

ANS: D
The ED charge nurse would direct additional nursing staff to help care for current ED clients while the ED staff prepares to receive mass casualty victims; however, they would not be assigned to the most critically ill or injured clients. The hospital incident commander’s role is to take a global view of the entire situation and facilitate patient movement through the system, while bringing in personnel and supply resources to meet patient needs. The medical command physician would kept the incident commander informed about victims and capacity of the ED.

Question 46

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. Encourage all staff to join a Disaster Medical Assistance Team.
b. Instruct all staff members to prepare go bags for all family members.
c. Use available resources for broad education and training in disaster management.
d. Provide incentives and bonuses for responding to mass casualty events.

Answer 46

ANS:C
Research indicates that education and training in disaster management before an incident occurs is associated with improved confidence and better coping after the incident. Go bags are important to maintain for all family members but would not be effective in mitigating stress. A DMAT is a medical relief team made up of civilian medical, paraprofessional, and support personnel that is deployed to a disaster area with enough medical equipment and supplies to sustain operations for 72 hours. Incentives and bonuses will not help mitigate stress.

Question 47

A nurse is caring for a client whose spouse died in a recent mass casualty accident. The client says, “I can’t believe that my spouse is gone and I am left to raise my children all by myself.” How would the nurse respond?

a. “Please accept my sympathies for your loss.”
b. “I can call the hospital chaplain if you wish.”
c. “You sound anxious about being a single parent.”
d. “At least your children still have you in their lives.”

Answer 47

ANS: C
Therapeutic communication includes active listening and honesty. This statement demonstrates that the nurse recognizes the client’s distress and has provided an opening for discussion. Extending sympathy and offering to call the chaplain do not give the client the opportunity to discuss feelings. Stating that the children still have one parent discounts the client’s feelings and situation.

Question 48

A nurse cares for victims during a community-wide disaster drill. One of the victims asks, “Why are the individuals with black tags not receiving any care?” How does the nurse respond?
a. “To do the greatest good for the greatest number of people, it is necessary to
sacrifice some.”
b. “Not everyone will survive a disaster, so it is best to identify those people early
and move on.”
c. “In a disaster, extensive resources are not used for one person at the expense of
many others.”
d. “With black tags, volunteers can identify those who are dying and can give them
comfort care.”

Answer 48

ANS: C
In a disaster, military-style triage is used; this approach identifies the dead or expectant dead with black tags. This practice helps to maintain the goal of triage, which is doing the most good for the most people. Precious resources are not used for those with overwhelming critical injury or illness, so that they can be allocated to others who have a reasonable expectation of survival. Victims are not “sacrificed.” Telling victims that is important to move on after identifying the expectant dead does not provide an adequate explanation and is callous. Victims are not black-tagged to allow volunteers to give comfort care.

Question 49

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?

a. The Medical Reserve Corps
b. The National Guard
c. The health department
d. A Disaster Medical Assistance Team

Answer 49

ANS: A
The Medical Reserve Corps (MRC) consists of volunteer medical and public health care professionals who support the community during times of need. They may help staff hospitals, establish first-aid stations or special needs shelters, or set up acute care centers in the community. The National Guard often performs search-and-rescue operations and law enforcement. The health department focuses on communicable disease tracking, treatment, and prevention. A Disaster Medical Assistance Team is deployed to a disaster area for up to 72 hours, providing many types of relief services.

Question 50

A nurse wants to become part oGfRaADDisEasSteLrAMBe.dCicOalMAssistance Team (DMAT) but is concerned about maintaining licensure in several different states. Which statement best addresses these concerns?
a. “Deployed DMAT providers are federal employees, so their licenses are good in
all 50 states.”
b. “The government has a program for quick licensure activation wherever you are
deployed.”
c. “During a time of crisis, licensure issues would not be the government’s priority
concern.”
d. “If you are deployed, you will be issued a temporary license in the state in which
you are working.”

Answer 50

ANS: A
When deployed, DMAT health care providers act as agents of the federal government, and so are considered federal employees. Thus their licenses are valid in all 50 states. Licensure is an issue that the government would be concerned with, but no programs for temporary licensure or rapid activation are available.

Question 51

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?

a. “Are you sure no more victims are coming into the ED?”
b. “Do all areas of the hospital have the supplies and personnel they need?”
c. “Have all ED staff had the chance to eat and rest recently?”
d. “Does the Chief Medical Officer agree this disaster is under control?”

Answer 51

ANS: B
Before “standing down,” the incident command officer ensures that the needs of the other hospital departments have been taken care of because they may still be stressed and may need continued support to keep functioning. Many more “walking wounded” victims may present to the ED; that number may not be predictable. Giving staff the chance to eat and rest is important, but all areas of the facility need that too. Although the Chief Medical Officer (CMO) may be involved in the incident, the CMO does not determine when the hospital can “stand down.”

Question 52

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?

a. Client who is still trying to locate relatives who are missing
b. Family awaiting the ability to travel out of state for temporary housing
c. Client with a score of 48 on the Impact of Event Scale-Revised (IES-R)
d. Client who has trouble sleeping and who startles easily

Answer 52

ANS: C
The IES-R is an assessment tool is a 22-item self-administered questionnaire that scores individuals on signs and symptoms of acute stress disorder or posttraumatic stress disorder. A score of 33 or higher out of 88 is a positive finding and this client would be referred a psychiatrist or other licensed mental health care provider. The nurse would administer the assessment to the client with difficulty sleeping after ensuring he or she can read at the 10th grade level, which is the reading level of the tool. The other two clients do not show evidence of particular needs for referral beyond what is usually provided in a natural disaster.

Question 53

A nurse is constructing a personal preparedness plan in case of a disaster. What does the nurse consider in making this plan?

a. Store basic supplies to last for at least 3 days.
b. Have short-term arrangements for child care.
c. Store enough frozen foods in freezer for 5 days.
d. Keep cooking utensils needed in a separate bag.

Answer 53

ANS: A
Concerns for their home and family can impact the willingness to report in an emergency and can be diminished by being prepared with a personal preparedness plan with enough supplies for 3 days. Any food needs to be nonperishable with no cooking required. Arrangements for children, pets, or older adults would be made for extended period of time.

Question 54

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? (Select all that apply.)

a. Partial-thickness burns covering both legs
b. Open fractures of both legs with absent pedal pulses
c. Neck injury and numbness of both legs
d. Small pieces of shrapnel embedded in both eyes
e. Head injury and difficult to arouse
f. Bruising and pain in the right lower abdomen

Answer 54

ANS: A,C,D,F
Clients with burns, spine injuries, eye injuries, and stable abdominal injuries would be treated within 30 minutes to 2 hours, and therefore would be identified with yellow tags. The client with the open fractures and the client with the head injury would be classified as urgent with red tags.

Question 55

A nurse triages clients arriving at the hospital after a mass casualty. Which clients are correctly classified? (Select all that apply.)

a. A 35-year-old female with severe chest pain: red tag
b. A 42-year-old male with full-thickness body burns: green tag
c. A 55-year-old female with a scalp laceration: black tag
d. A 60-year-old male with an open fracture with distal pulses: yellow tag
e. An 88-year-old male with shortness of breath and chest bruises: green tag
f. A 33-year-old male unconscious with bilateral leg amputations: yellow

Answer 55

ANS: A,D
Red-tagged clients need immediate care due to life-threatening injuries. A client with severe chest pain would receive a red tag. Yellow-tagged clients have major injuries that need to be treated within 30 minutes to 2 hours. A client with an open fracture with distal pulses would receive a yellow tag. The client with full-thickness body burns would receive a black tag. The client with a scalp laceration would receive a green tag, and the client with shortness of breath would receive a red tag. The client with the amputated legs will probably be black tagged if the unconsciousness is from massive blood loss.

Question 56

A hospital prepares for a mass casualty event. Which functions are correctly paired with the personnel role? (Select all that apply.)
a. Paramedic—decides the number, acuity, and resource needs of clients
b. Hospital incident commander—assumes overall leadership for implementing theemergency plan
c. Public information officer—provides advanced life support during transportation
to the hospital
d. Triage officer—rapidly evaluates each client to determine priorities for treatment
e. Medical command physician—serves as a liaison between the health care facility
and the media

Answer 56

ANS: B,D
The hospital incident commander assumes overall leadership for implementing the emergency plan. The triage officer rapidly evaluates each client to determine priorities for treatment. The paramedic provides advanced life support during transportation to the hospital. The public information officer serves as a liaison between the health care facility and the media. The medical command physician decides the number, acuity, and resource needs of clients.

Question 57

A new graduate nurse has started working on a medical-surgical unit. What actions would the nurse take to be prepared for a disaster? (Select all that apply.)

a. Know the institution’s Emergency Response Plan.
b. Participate in the institution’s disaster drill.
c. Develop a personal preparedness plan.
d. Understand that nurses play a role in every phase of a disaster.
e. Be prepared to report immediately to the emergency department.
f. Be willing to be flexible working during a crisis situation.

Answer 57

ANS: A,B,C,D,F
Nurses play a major role in disaster and need to be prepared for any type of disaster. Knowing the institution’s emergency management plan and participating in disaster drills will help the nurse be prepared for a disaster. Concerns for their home and family can impact the willingness to report in an emergency and can be diminished by being prepared with a personal preparedness plan. Nurses play key roles before, during, and after a disaster in the development of emergency management plan in defining specific nursing roles. During a crisis, nurses may be assigned to different areas of the facility or to different job functions and must remain flexible while working to their best ability.