The triage nurse is working in the emergency department.

Which client should be

assessed first?

1. The 10-year-old child whose dad thinks the child's leg is broken.

2. The 45-year-old male who is diaphoretic and clutching his chest.

3. The 58-year-old female complaining of a headache and seeing spots.

4. The 25-year-old male who cut his hand with a hunting knife.

The nurse is teaching a class on disaster preparedness. Which are components of an

Emergency Operations Plan (EOP)? Select all that apply.

1. A plan for practice drills.

2. A deactivation response.

3. A plan for internal communication only.

4. A pre-incident response.

5. A security plan.

According to the North Atlantic Treaty Organization (NATO) triage system, which

situation is considered a level red (Priority 1)?

1. Injuries are extensive and chances of survival are unlikely.

2. Injuries are minor and treatment can be delayed hours to days.

3. Injuries are significant but can wait hours without threat to life or limb.

4. Injuries are life threatening but survivable with minimal interventions.

Which statement best describes the role of the medical-surgical nurse during a

disaster?

1. The nurse may be assigned to ride in the ambulance.

2. The nurse may be assigned as a first assistant in the operating room.

3. The nurse may be assigned to crowd control.

4. The nurse may be assigned to the emergency department.

The nurse in a disaster is triaging the following clients. Which client should be

triaged as an Expectant Category, Priority 4, and color black?

1. The client with a sucking chest wound who is alert.

2. The client with a head injury who is unresponsive.

3. The client with an abdominal wound and stable vital signs.

4. The client with a sprained ankle which may be fractured.

Which federal agency is a resource for the nurse volunteering at the American Red

Cross who is on a committee to prepare the community for any type of disaster?

1. The Joint Commission (JC).

2. Office of Emergency Management (OEM).

3. Department of Health and Human Services (DHHS).

4. Metro Medical Response Systems (MMRS).

Which situation requires the emergency department manager to schedule and

conduct a Critical Incident Stress Management (CISM)?

1. Caring for a two (2)-year-old child who died from severe physical abuse.

2. Performing CPR on a middle-aged male executive who died.

3. Responding to a 22-victim bus accident with no apparent fatalities.

4. Being required to work 16 hours without taking a break.

During a disaster, a local news reporter comes to the emergency department

requesting information about the victims. Which action is most appropriate for the

nurse to implement?

1. Have security escort the reporter off the premises.

2. Direct the reporter to the disaster command post.

3. Tell the reporter this is a violation of HIPAA.

4. Request the reporter to stay out of the way.

The triage nurse has placed a disaster tag on the client. Which action warrants

immediate intervention by the nurse?

1. The nurse documents the tag number in the disaster log.

2. The unlicensed assistive personnel documents vital signs on the tag.

3. The health-care provider removes the tag to examine the limb.

4. The LPN securely attaches the tag to the client's foot.

The father of a child brought to the emergency department is yelling at the staff and

obviously intoxicated. Which approach should the nurse take with the father?

1. Talk to the father in a calm and low voice.

2. Tell the father to wait in the waiting room.

3. Notify the child's mother to come to the ED.

4. Call the police department to come and arrest him.

A gang war has resulted in 12 young males being brought to the emergency

department. Which action by the nurse is priority when a gang member points a gun

at a rival gang member in the trauma room?

1. Attempt to talk to the person who has the gun.

2. Explain to the person the police are coming.

3. Stand between the client and the man with the gun.
4. Get out of the line of fire and protect self.

A nursing student is studying about disasters and emergency preparedness. Which of the following statements by the
nursing student depicts a correct understanding of the difference between a disaster and an emergency?

a-"Disasters are man made only."

b-"An emergency is an unforeseen combination of circumstances calling for immediate action for a range of victims."

c-"Man made disasters are intentional only."

d-"Emergencies are caused by acts of nature or emerging diseases."

An emergency room nurse is working when there is a bioterrorism attack in the city. Which of the following statements
is a correct with regard to injuries or symptoms associated with a bioterrorism attack?

a-The main purpose of biological weapon use is contained devastation.

b-It is not uncommon for the results of a biological attack to be made known several hours or days after the attack.

c-Biological attacks are usually known right away.

d-Detection is easy as clients go to a number of different health care facilities.

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

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.

Which of these is not classified as a Category A biologic agent?

a-Staphylococcus enterotoxin B (SEB).

b-Clostridium botulinum toxin (botulism).

c-Bacillus anthracis (anthrax).

d-Francisella tularensis (tularemia).

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.

The nurse has been assigned the role of triage nurse after a weather-related disaster. What is the priority action of the
nurse?

a. Call in additional staff to assist with care of the victims.

b. Splint fractures and clean and dress lacerations.

c. Perform a rapid assessment of clients to determine priority of care.

d. Provide psychological support to staff and family members.

An Emergency Department nurse is informed of a nearby bombing at the office building. This nurse needs to be aware of
the principles of triage and decontamination. In which zone does decontamination usually occur?

1. In the hot zone

2. In the warm zone

3. In the cold zone

4. In the artic zone

Ratio: The site of the disaster where a weapon was released or where the contamination occurred is called the hot zone.
It is considered contaminated, and only those persons in the appropriate personal protective equipment may enter this
zone. The warm zone is adjacent to the hot zone. Another name for this area is the control zone. This area is where the
decontamination of victims or triage and emergency treatment takes place. The cold zone is considered to be the safe
zone.

A chemical plant has had a chemical leak. The nurse manager in the local emergency room receives information that
this disaster is assigned a status of Level II, which indicates:

A) Local emergency response teams can manage the situation.

B) Regional efforts and aid from surrounding communities can manage the situation.

C) Statewide or federal assistance is required.

D) The area must be evacuated immediately.

The nursing supervisor working the night shift when she receives information that a destructive earthquake has
occurred within the vicinity recognizes that she will be working with several organizations in the management of this
disaster. She recalls that the organization responsible for coordinating interagency relief assistance is the:

A) Office of Emergency Management

B) Incident Command System

C) Centers for Disease Control and Prevention (CDC)

D) American Red Cross

Feedback: The Office of Emergency Management coordinates the disaster relief efforts at state and local levels. The
Incident Command System is a management tool to organize personnel, facilities, equipment, and communication in an
emergency situation. The CDC is the agency for disease prevention and control that supports state and local health
departments. The American Red Cross provides additional support.

A hospital committee is in the preparatory stages of developing an emergency operations plan (EOP). Which of the
following actions take place during the post-incident response of an emergency operations plan?

A) It is decided when the facility goes from disaster response to daily activities.

B) Practice drills are conducted for the community and facility.

C) A critique and debriefing occur for all involved immediately and at later dates.

D) Replacement of resources occurs in the facility.

A 40-year-old male patient who was at the site of a workplace explosion that is considered a disaster area has suffered
second- and third-degree burns to 65% of his body, but he is conscious. This person would be triaged as:

A) Green

B) Yellow

C) Red

D) Black

Feedback: The purpose of triaging in a disaster is to do the greatest good for the greatest number of people. This patient
is triaged as black.

A nurse caring for patients exposed to a terrorist attack involving chemicals has been advised that personal protective
equipment must be worn to give the highest level of respiratory protection with a lesser level of skin and eye protection.
This is considered:

A) Level A

B) Level B

C) Level C

D) Level D

Rationale: Level B personal protective equipment provides the highest level of respiratory protection, with a lesser level
of skin and eye protection. Level A provides the highest level of respiratory, mucous membrane, skin, and eye protection.
Level C incorporates the use of an air-purified respirator, a chemical-resistant coverall with splash hood, chemical-
resistant gloves, and boots. Level D is the same as a work uniform.

A Level C personal protective equipment requirement is needed when caring for a patient. The nurse is aware that the
equipment will include a(n):

A) Self-contained breathing apparatus

B) Vapor-tight, chemical resistant suit

C) Uniform only

D) Air-purified respiratory

Feedback: Level C incorporates the use of an air-purified respirator, a chemical-resistant coverall with splash hood,
chemical-resistant gloves, and boots. Level A provides the highest level of respiratory, mucous membrane, skin, and eye
protection, incorporating a vapor-tight chemical-resistant suit and self-contained breathing apparatus (SCBA). Level B
personal protective equipment provides the highest level of respiratory protection, with a lesser level of skin and eye
protection, incorporating a chemical-resistant suit and SCBA. Level D is the same as a work uniform.
A patient has been transported to an emergency room from the scene of a terrorist chemical attack. The emergency
room staff members have been trained to follow steps that decrease the risk of secondary exposure to a chemical used
in a terrorist attack. Which of the following initial steps must be implemented?

A) Decontamination

B) Universal precautions

C) Defusing

D) Triaging

Feedback: Decontamination must be implemented to remove the accumulated contaminants and decrease the risk of
secondary exposure and contamination.

A patient has been exposed to anthrax by inhalation. Which of the following signs and symptoms would indicate that the
patient is in the second stage of infection?

A) Headache

B) Vomiting

C) Syncope

D) Cyanosis

Feedback: The second stage of anthrax infection by inhalation includes severe respiratory distress, including stridor,
cyanosis, hypoxia, diaphoresis, hypotension, and shock. The first stage includes flu-like symptoms.

Which of the following precautions must be put in place for a patient who has been exposed to anthrax by inhalation?

A) Standard

B) Airborne

C) Droplet

D) Contact

Feedback: The patient is not contagious. Since anthrax cannot be spread from person to person, standard precautions
are initiated.

The nurse is aware that the patient suspected of being exposed to the smallpox virus is contagious:

A) Immediately after exposure

B) Only when pustules form

C) After a rash appears

D) With a body temperature of 38° C

A patient who is a victim of a terrorist attack involving a chemical agent presents to the emergency department with
visual disturbances, nausea, vomiting, forgetfulness, and irritability. The nurse suspects this patient has been exposed to
which of the following chemical agents?

A) Nerve

B) Pulmonary

C) Vesicants

D) Blood
The nurse expects the patient who has been admitted after exposure to a nerve agent to be treated with which of the
following?

A) Nitrate

B) Dimercaprol

C) Erythromycin

D) Atropine

Feedback: Atropine is administered when a patient is exposed to a nerve agent. Exposure to blood agents, such as
cyanide, require treatment with amyl nitrate, sodium nitrite, and sodium thiosulfate. Dimercaprol is administered
intravenously for systemic toxicity and topically for skin lesions when exposed to vesicants.

After being exposed to a dose of more than 5000 rads of radiation during a terrorist bombing, the patient's skin will
show which of the following manifestations within a few days to months?

A) Erythema

B) Recurring erythema

C) Desquamation

D) Necrosis

Feedback: Necrosis of the skin becomes evident within a few days to months at doses of more than 5000 rads. With
600 to 1000 rads, erythema occurs; it can disappear within hours and then reappear. At greater than 1000 rads,
desquamation (radiation dermatitis) of the skin occurs.

A 44-year-old male patient has been exposed to radiation. Which of the following is the most accurate statement
regarding decontamination?

A) Alcohol and iodine scrubs are necessary.

B) Soap and water scrubs are necessary.

C) The patient should be assessed in the emergency room before decontamination.

D) The patient's clothing is double bagged and stored inside the facility.

Feedback: The majority of patients can be safely decontaminated with soap and water. Waste is controlled through
double bagging and plastic-lined containers outside of the facility. Triage outside the hospital is the most effective
means of preventing contamination of the facility itself.

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

Rationale: 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.

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

Rationale: 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".

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.

Rationale: 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

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

Rationale: 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.

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 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 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 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 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 nurse is the first responder after a tornado has destroyed many homes in the community. Which victim should the
nurse attend to first?

1.A pregnant woman who exclaims, "My baby is not moving."

2.A child who is complaining, "My leg is bleeding so bad, I am afraid it is going to fall off!"

3.A young child standing next to an adult family member who is screaming, "I want my mommy!"

4.An older victim who is sitting next to her husband sobbing, "My husband is dead. My husband is dead."

Rationale: Priority nursing care in disaster situations needs to be delivered to the living and not the dead. The child who
is bleeding badly is the priority. The bleeding could be from an arterial vessel; if the bleeding is not stopped, the child is
at risk for shock and death. The pregnant client is the next priority, but the absence of fetal movement may or may not
be indicative of fetal demise. The young child is with a family member and is safe at this time. The older victim will need
comfort measures; there is no information indicating she is physically hurt.

R.213 NCLEX Questions - Triage & Emergency Preparedness

Study
NUR.213 NCLEX Questions - Triage & Emergency Preparedness

47 studiers today

4.9 (27 reviews)

Games and activities

Quizlet Live

New

Blast

Match

Checkpoint

In-class review

Flashcards

Learn

Test

Profile Picture

Created by

Nurse411

Teacher

Share

Terms in this set (13)

Original

The nurse is the first responder after a tornado has destroyed many homes in the community. Which victim should the
nurse attend to first?

1.

A pregnant woman who exclaims, "My baby is not moving."

2.

A child who is complaining, "My leg is bleeding so bad, I am afraid it is going to fall off!"

3.

A young child standing next to an adult family member who is screaming, "I want my mommy!"

4.

An older victim who is sitting next to her husband sobbing, "My husband is dead. My husband is dead."
2.

A child who is complaining, "My leg is bleeding so bad, I am afraid it is going to fall off!"

Priority nursing care in disaster situations needs to be delivered to the living and not the dead. The child who is bleeding
badly is the priority. The bleeding could be from an arterial vessel; if the bleeding is not stopped, the child is at risk for
shock and death. The pregnant client is the next priority, but the absence of fetal movement may or may not be
indicative of fetal demise. The young child is with a family member and is safe at this time. The older victim will need
comfort measures; there is no information indicating she is physically hurt.

The community health nurse is working with disaster relief after a tornado. The nurse assists in finding safe housing for
survivors, providing support to families, organizing counseling, and securing physical care when needed. Which level of
prevention does the nurse exercise?

1.Primary level of prevention

2.Secondary level of prevention

3.Tertiary level of prevention

4.Quaternary level of prevention

Rationale: Tertiary prevention involves reduction of the amount and degree of disability, injury, and damage after a crisis.
Primary prevention means keeping the crisis from occurring, and secondary prevention focuses on reducing the intensity
and duration of a crisis. There is no known quaternary prevention level.

The nurse in the hospital emergency department is notified by emergency medical services that several victims who
survived a plane crash will be transported to the hospital. Victims are suffering from cold exposure because the plane
plummeted and was submerged in a local river. What is the initial action of the nurse?

1.Call the nursing supervisor to activate the agency disaster plan.

2.Supply the triage rooms with bottles of sterile water and normal saline.

3.Call the intensive care unit to request that nurses be sent to the emergency department.

4.Call the laundry department, and ask the department to send as many warm blankets as possible to the emergency
department.

Rationale: In an external disaster, many people may be brought to the emergency department for treatment. The initial
nursing action must be to activate the disaster plan. Although options 2, 3, and 4 may be additional measures that the
nurse would take, the initial action would be to activate the disaster plan.

The nurse is reviewing the manual of disaster preparedness and response for the annual hospital disaster drill. The
nurse reads that which are functions of the American Red Cross (ARC) as opposed to the Federal Emergency
Management Agency (FEMA) in the United States? Select all that apply.

1.Provide monetary relief.

2.Provide crisis counseling.

3.Identify and train personnel.

4.Issue presidential declarations.

5.Deploy National Guard troops.

6.Handle inquiries from families

Rationale: In general, the ARC provides support to individuals involved in a disaster, whereas FEMA deals with regional
responses to disasters, such as issuing presidential declarations, providing monetary relief, and deploying National
Guard troops. The ARC has been given authority by the federal government to identify and train personnel for a disaster
and provide disaster relief, including crisis counseling, operating shelters, and handling inquiries from families.
The community health nurse is preparing to teach personnel and family preparedness for disasters to a group of parents
of school-age children. Which items should the nurse plan to include in disaster preparedness? Select all that apply.

1.Flashlight

2.Supply of batteries

3.Battery-operated radio

4.Extra pair of eyeglasses

5.4-week supply of water

6.4-week supply of nonperishable food

The nurse is the first responder at the scene of a 6-car crash on a highway. Which victim should the nurse attend to first?

1.A victim experiencing dyspnea

2.A victim experiencing confusion

3.A victim experiencing tachycardia

4.A victim experiencing intense pain

The nurse in charge of a nursing unit is asked to select the hospitalized clients who can be discharged so that hospital
beds can be made available for victims of a community disaster. Which clients can be safely discharged? Select all that
apply.

1.A client with chest pain

2.A client with a Holter monitor

3.A client receiving oral antibiotics

4.A client experiencing sinus rhythm

5.A client newly diagnosed with atrial fibrillation

6.A client experiencing third-degree heart block who requires a pacemaker

The nurse in charge of a nursing unit is asked to select those hospitalized clients who can be discharged so that
hospital beds can be made available for victims of a community disaster. Which clients can be safely discharged? Select
all that apply.

1.The client with heart failure (HF) who has bilateral rhonchi

2.The client who 24 hours earlier gave birth to her second child by caesarean delivery

3.The 48-hour postoperative client who has undergone an ileostomy because of ulcerative colitis

4.The client with peritonitis caused by a ruptured appendix who is febrile with a temperature of 102°F (38.9°C)

5.The 2-day postoperative client who has undergone total knee replacement and is ambulating with a walker

6.The 3-day postoperative client who has undergone coronary artery bypass grafting and is ready for rehabilitation

The nurse from a medical unit is called to assist with care for clients coming into the hospital emergency department
during an external disaster. Using principles of triage during a disaster, the nurse should attend to the client with which
problem first?

1.Fractured tibia

2.Penetrating abdominal injury

3.Bright red bleeding from a neck wound

4.Open massive head injury in deep coma

Rationale: The client with arterial bleeding from a neck wound is in immediate need of treatment to save the client's life.
This client is classified as such and would wear a color tag of red from the triage process. The client with a penetrating
abdominal injury would be tagged yellow and classified as "delayed," requiring intervention within 30 to 60 minutes. A
green or "minimal" designation would be given to the client with a fractured tibia, who requires intervention but who can
provide self-care if needed. A designation of expectant is applied to the client with massive head or other injuries and
minimal chance of survival; the corresponding color code is black in the triage process. Such clients receive supportive
care and pain management but are given definitive treatment last.

The nurse is the first responder at the scene of a train accident. Which victim should the nurse attend to first?

1.A victim experiencing excruciating pain

2.A victim experiencing moderate anxiety

3.A victim experiencing airway obstruction

4.A victim experiencing altered level of consciousness

The nurse in charge of a nursing unit is asked to select the hospitalized clients who can be discharged so that hospital
beds can be made available for victims of a community disaster. Select the clients who can be safely discharged. Select
all that apply.

1.A client with dyspnea

2.A client experiencing sinus rhythm

3.A client receiving oral anticoagulants

4.A client with chronic atrial fibrillation

5.A client experiencing third-degree heart block

6.A client who has not voided since before surgery

Rationale: Clients should be medically stable if discharged and should be able to manage their condition at home
independently, with family assistance, or with community services. The client in option 2 is stable because sinus rhythm
is a normal finding. Oral anticoagulants can be taken at home as long as the client understands how to take the
medication and is provided with education about the medication. The client in option 4 can be discharged because the
client's condition is chronic, not acute. The client experiencing dyspnea is not considered stable. The client experiencing
third-degree heart block is considered unstable and will most likely need a pacemaker insertion. Clients should not be
discharged after surgery until they have voided.

The nurse is the first responder at the scene of a train accident. Which victim should the nurse attend to first?

1.A middle-aged man with 1 foot trapped under the wreckage

2.A crying teenager who is holding pressure on an arm laceration

3.A young woman who appears dazed and confused and is shivering

4.A screaming middle-aged woman looking frantically for her husband

Rationale: The young woman is demonstrating classic signs of shock, possibly from a closed head injury. Initial
management of a client displaying signs of shock includes management of airway, breathing, and circulation. Initial
treatment includes keeping the client warm. Oxygenation and intravenous fluids will be needed immediately to stabilize
and maintain tissue perfusion. A first responder would be unlikely to be able to release a foot trapped under wreckage
without help. The teenager is already applying pressure to the arm and is more likely to be able to maintain self-care until
help arrives. Assisting a client with search and rescue would only be feasible once help arrives. Therefore, the nurse
should attend to the client with the priority needs and the greatest potential of survival.
Which client should the emergency department triage nurse classify as emergent?

1.A client with a displaced fracture who is crying

2.A client with a simple laceration and soft tissue injury

3.A client with crushing substernal pain who is short of breath

4.A client with a temperature of 101°F (38.3°C) with a productive cough

Rationale: A triage method commonly used in the emergency department consists of 3 categories: emergent, urgent,
and nonurgent. The emergent category implies that a condition exists that poses an immediate threat to life or limb. An
example of a client who fits into this category is the client experiencing crushing substernal pain who is short of breath.
The urgent category indicates that the client should be treated quickly but that an immediate threat to life does not exist
at the moment. The client with a displaced fracture who is crying and the client with a temperature of 101°F (38.3°C) and
a productive cough would fit into this category. The nonurgent category indicates that the client can generally tolerate
waiting several hours for health care services without a significant risk of clinical deterioration. The client with a simple
laceration and soft tissue injury would fit into this category.

While assessing a client in the emergency department, the nurse identifies that the client has been raped. Which health
care team member should the nurse collaborate with when planning this client's care?

a. Emergency medicine physician

b. Case manager

c. Forensic nurse examiner

d. Psychiatric crisis nurse

Rationale: 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.

On admission to the emergency department, a client states that he feels like killing himself. When planning this client's
care, it is most important for the nurse to coordinate with which member of the health care team?

a. Case manager

b. Forensic nurse examiner

c. Physician

d. Psychiatric crisis nurse

Rationale: The psychiatric crisis nurse interacts with clients and families in crisis. This health care team member can
offer valuable expertise to the emergency health care team, which also includes the case manager and the physician.

Which interventions will be performed during the primary survey for a trauma client? (Select all that apply.)

a. Removing wet clothing

b. Splinting open fractures

c. Initiating IV fluids

d. Endotracheal intubation

e. Foley catheterization

f. Needle decompression

g. Laceration repair

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: A, airway
and cervical spine control; B, breathing; C, circulation; D, disability; and E, exposure. After completion of primary
diagnostic studies and laboratory studies, and insertion of gastric and urinary tubes, the secondary survey, a complete
head-to-toe assessment, can be carried out.

The nurse is assessing clients on site at a multi-vehicle accident. Triage clients in the order they should receive care.
(Place in order of priority.)

a. A 50-year-old with chest trauma and difficulty breathing

b. A mother frantically looking for her 6-year-old son

c. An 8-year-old with a broken leg in his father's arms

d. A 60-year-old with facial lacerations and confusion

e. A pulseless male with a penetrating head wound

ANS:a, d, b, c, e

Rationale: Clients should be prioritized with ABCs and emergent, urgent, and nonurgent status. The client with chest
trauma and difficulty breathing is the priority because no clients have an airway problem, and this is the only client with a
breathing problem. The client with confusion should be seen next. Confusion can be caused by lack of oxygen to the
brain due to a circulation problem. The pulseless client with a penetrating head wound is seen last because there are
multiple clients to be seen, and care for this client would be futile. The client with a broken leg is nonurgent and can wait.
The mother looking for her son should be seen third. Finding the child is urgent to identify potential injuries.

A patient comes into the emergency department with a chemical burn from contact with lye.Assessment and treatment
of this patient will be based on what knowledge regarding this type of burn? (Select all that apply)

1. This is an alkali burn.

2. This type of burn tends to be deeper.

3. This is an acid burn.

4. This type of burn will be easier to neutralize.

5. This type of burn tends to be more superficial.

Rationale: This is an alkali burn which is more difficult to neutralize than an acid burn and tends to have a deeper
penetration and be more severe than a burn caused by an acid.

A patient arrives at the emergency department with an electrical burn. What assessment questions should the nurse ask
in determining the possible severity of the burn injury? Select all that apply.

1. What type of current was involved?

2. How long was the patient in contact with the current?

3. How much voltage was involved?

4. Where was the patient when the burn occurred?

5. What was the point of contact with the current?

Rationale: The severity of electrical burns depends on the type and duration of the current and amount of voltage.
Location is not important in determining possible severity. Location is not important in determining possible severity.

A nurse sees a patient get struck by lightning during a thunder storm on a golf course. What should be the FIRST action
by the nurse?

1. Check breathing and circulation.

2. Look for entrance and exit wounds.

3. Cover the patient to prevent heat loss.

4. Move the patient indoors to a dry place.

5. Get the patient up off the ground.

Rationale: Cardiopulmonary arrest is the most common cause of death from lightening. Respiratory and cardiac status
should be assessed immediately to determine if CPR is necessary. All other actions are secondary.

A nurse is teaching a class of older adults at a senior center about household cleaning agents that may cause burns.
Which agents should be included in these instructions?

(Select all that apply)

1. drain cleaners

2. household ammonia

3. oven cleaner

4. toiler bowl cleaner

5. lemon oil furniture polish

A patient, experiencing a burn that is pale and waxy with large flat blisters, asks the nurse about the severity of the burn
and how long it will take to heal. With which of the following should the nurse respond to this patient?

1. The wound is a deep partial-thickness burn, and will take more than three weeks to heal.

2. The wound is a partial-thickness burn, and could take up to two weeks to heal.

3. The wound is a superficial burn, and will take up to three weeks to heal.

4. The wound is a full-thickness burn and will take one to two weeks to heal.

5. Wound healing is individualized.

Rationale: The wound described is a deep partial-thickness burn. Deep partial-thickness wounds will take more than
three weeks to heal. A superficial burn is bright red and moist, and might appear glistening with blister formation. The
healing time for this type of wound is within 21 days. A full thickness burn involves all layers of the skin and may extend
into the underlying tissue. These burns take many weeks to heal. Stating that wound healing is individualized does not
answer the patient's question about the severity of the burn.

In order for the nurse to correctly classify a burn injury, which of the following does the nurse need to assess?

Select all that apply.

1. the depth of the burn

2. extent of burns on the body

3. the causative agent and the duration of exposure.

4. location of burns on the body

5. the time that the burn occurred

Rationale: Depth of the burn (the layers of underlying tissue affected) and extent of the burn (the percentage of body
surface area involved) are used in determining the amount of tissue damage and classification of the burn.The causative
agent is especially important with chemical burns such as from strong acids or alkaline agents. The location of the
burns on the body is one of the important determinates of classification. For example, burns of the face and hands are
always considered major burns. Time of occurrence of the burn is not necessary for classification.

A patient has a scald burn on the arm that is bright red, moist, and has several blisters. The nurse would classify this
burn as which of the following?

Select all that apply.

1. a superficial partial-thickness burn

2. a thermal burn

3. a superficial burn

4. a deep partial-thickness burn

5. a full-thickness burn

Rationale: Superficial partial-thickness burn if often bright red, has a moist, glistening appearance and blister formation.
Thermal burns result from exposure to dry or moist heat. A superficial burn is reddened with possible slight edema over
the area. A deep partial-thickness burn often appears waxy and pale and may be moist or dry. A full-thickness burn may
appear pale, waxy, yellow, brown, mottled, charred, or non-blanching red with a dry, leathery, firm wound surface.

A 25-year-old patient is admitted with partial-thickness injuries over 20% of the total body surface area involving both
lower legs. The nurse would classify this injury as being which of the following?

1. a moderate burn

2. a minor burn

3. a major burn

4. a severe burn

5. an intermediate burn

Rationale: A moderate burn is a partial-thickness injury that is between 15%-25% of total body surface area in adults.

of 28% of total body surface area (TBSA) and full-thickness injury of 30% or greater of TBSA. How should the nurse
classify this burn injury?

1. major

2. moderate

3. minor

4. superficial

5. intermediate

Rationale: Partial-thickness injuries of greater than 25% of total body surface area in adults and full-thickness injuries
10% or greater of TBSA are considered major burns.

A 70-year-old patient has experienced a sunburn over much of the body. What self-care technique is MOST important to
emphasize to an older adult in dealing with the effects of the sunburn?

1. increasing fluid intake

2. applying mild lotions

3. taking mild analgesics

4. maintaining warmth

5. using sunscreen

Rationale: Older adults are especially prone to dehydration; therefore, increasing fluid intake is especially important.
Other manifestations could include nausea and vomiting. All the measures help alleviate the manifestations of this
minor burn which include pain, skin redness, chills, and headache. Use of sunscreen is a preventative, not a treatment
measure.

A patient is being discharged after treatment for a scald burn that caused a superficial burn over one hand and a
superficial partial-thickness burn on several fingers. What should be included in this patient's discharge instructions?

(Select all that apply)

1. Report any fever to your healthcare provider.

2. Report development of purulent drainage to your healthcare provider.

3. Use only sterile dressings on the fingers.

4. Cleanse the areas every hour with alcohol to prevent infection.

5. Apply the topical antimicrobial agent as instructed.

Rationale: Fever or purulent drainage are indicative of development of infection and should be reported to the healthcare
provider. Sterile dressings only should be used on the areas of the superficial partial-thickness burns where the skin is
not intact. Cleansing is necessary no more often than daily to the intact skin areas and only soap and water should be
used, not alcohol. Topical agents may be ordered by the health care provider and the patient should follow directions for
applying to help prevent infection of the areas.

The nurse is reviewing the results of laboratory tests to assess the renal status of a patient who experienced a major
burn event on 45% of the body 24 hours ago. Which of the following results would the nurse expect to see?

(Select all that apply)

1. glomerular filtration rate (GFR) reduced

2. specific gravity elevated

3. creatinine clearance reduced

4. BUN reduced

5. uric acid decreased

Rationale: During the initial phases of a burn injury, blood flow to the renal system is reduced, resulting in reduction in
GFR and an increase in specific gravity. During this period, BUN levels, creatinine, and uric acid are increased

When evaluating the laboratory values of the burn-injured patient, which of the following can be anticipated?

1. decreased hemoglobin and elevated hematocrit levels

2. elevated hemoglobin and elevated hematocrit levels

3. elevated hemoglobin and decreased hematocrit levels

4. decreased hemoglobin and decreased hematocrit levels

5. hemoglobin and hematocrit levels within normal ranges

Rationale: Hemoglobin levels are reduced in response to the hemolysis of red blood cells. Hematocrit levels are elevated
secondary to hemoconcentration, and fluid shifts from the intravascular compartment.

When monitoring the vital signs of the patient who has experienced a major burn injury, the nurse assesses a heart rate
of 112 and a temperature of 99.9° F. Which of the following best describes the findings?

1. These values are normal for the patient's post-burn injury condition.

2. The patient is demonstrating manifestations consistent with the onset of an infection.

3. The patient is demonstrating manifestations consistent with an electrolyte imbalance.

4. The patient is demonstrating manifestations consistent with renal failure.

5. The patient is demonstrating manifestations of fluid volume overload.

Rationale: The burn-injured patient is not considered tachycardic until the heart rate reaches 120 beats per minute. In the
absence of other symptoms, the temperature does not signal the presence of an infection. It could be a response to a
hypermetabolic response.
A patient recovering from a major burn injury is complaining of pain. Which of the following medications will be most
therapeutic to the patient?

1. morphine 4 mg IV every 5 minutes

2. morphine 10 mg IM ever 3-4 hours

3. meperidine 75 mg IM every 3-4 hours

4. meperidine 50 mg PO every 3-4 hours

5. fentanyl citrate (Duragesic) 75 mcg patch every 3 days

Rationale: Morphine is preferred over meperidine for the burn-injured patient. Typical dose of morphine is 3-5 mg every 5
-10 minutes for an adult. The intravenous route is preferred over oral and intramuscular routes. A transdermal patch
would not be used because of decreased absorption of the medication through the skin of the burn-injured patient.

A patient is admitted to the emergency department with deep partial-thickness burns over 35 % of the body. What IV
solution will be started initially?

1. warmed lactated Ringer's solution

2. dextrose 5% with saline solution

3. dextrose 5% with water

4. normal saline solution

5. 0.45% saline solution

Rationale: Warmed lactated Ringer's solution is the IV solution of choice because it most closely approximates the
body's extracellular fluid composition. It is warmed to prevent hypothermia.

Using the modified Brooke formula, calculate the amount of intravenous solution that will be administered in the first 8
hours for a patient with 40% TBSA and weighs 52 kg.

Correct Answer: 2080 mL

Rationale : The modified Brooke formula is 2 mL × total kg of body weight × % TBSA. In this situation, 2 mL × 52 kg × 40
= 4160 mL. One-half is given over the first eight hours, or 2080 mL.

The family of a patient with third-degree burns wants to know why the "scabs are being cut off" of the patient's leg. What
is the most appropriate response by the nurse to this family?

1. "The scabs are really old burned tissue and need to be removed to promote healing."

2. "I'll ask the doctor to come and talk with you about the treatment plan."

3. "The patient asked for the scabs to be removed."

4. "The scabs are removed to check for blood flow to the burned area."

Rationale: The patient's family is describing eschar, which is the hard crust of burned necrotic tissue. Eschar needs to be
removed to promote wound healing. Option 2 does not answer the family's question. Option 3 incorrectly restates the
family's concern. Scabs are not removed to check for blood flow

A patient is coming into the emergency department with third-degree burns over 25% of his body. The nurse should
prepare which of the following solutions for intravenous infusion for this patient?

1. warmed lactated Ringer's

2. 5% dextrose in water

3. 5% dextrose in 0.45 normal saline

4. 5% dextrose in normal saline

Rationale: Warmed Ringer's lactate solution is the intravenous fluid most widely used during the first 24 hours after a
burn injury because it most closely approximates the body's extracellular fluid composition.

A patient with third-degree burns to her face just learned that she will have extensive scarring once the burn heals.
Which of the following nursing diagnoses would be applicable to this patient at this time?

1. Powerlessness

2. Potential for Infection

3. Fluid Volume Deficit

4. Risk for Ineffective Airway Clearance

Rationale: This patient can begin to experience powerlessness in that she has no control over the outcome of healing on
scar formation to her face. The nurse should allow the patient to express feelings in efforts to help the patient cope with
the news of potential scarring. The patient with a third-degree burn is at risk for infection, however, this question is
focused on the impact of her facial scarring. There is inadequate information to determine the patient's risk for fluid
volume deficit or ineffective airway clearance. Further, this is not the focus of the question.

A patient comes into the clinic to be seen for a burn that appears moist with blisters. The nurse realizes that this patient
most likely has experienced which of the following?

1. first-degree burn

2. superficial second-degree burn

3. deep second-degree burn

4. third-degree burn

Rationale: Partial-thickness, or second-degree, burns can either be superficial or deep. This patient's burn, which appears
moist with blisters, is consistent with a superficial second-degree burn. A first-degree burn would involve only the
surface layer of skin. Redness would be expected. Deep second-degree and third-degree burns would be deeper and
involve more damage to the dermis, epidermis, and underlying tissue

A hospital responds to a local mass casualty event. Which action should the nurse supervisor take to prevent staff post-
traumatic stress disorder during a mass casualty 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.

Rationale: To prevent staff post-traumatic stress disorder during a mass casualty event, the nurses should use available
counseling, encourage and support co-workers, monitor each others 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
should also keep in touch with family, friends, and significant others, and not work for more than 12 hours per 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 post-traumatic stress disorder.

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 ED 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.

Rationale: The ED charge nurse should direct additional nursing staff to help care for current ED clients while the ED
staff prepares to receive mass casualty victims; however, they should not be assigned to the most critically ill or injured
clients. The house supervisor and unit directors would collaborate to discharge stable clients. The hospital incident
commander is responsible for mobilizing resources and would have the responsibility for calling in staff. The medical
command physician would be the person best able to communicate with on-scene personnel regarding the ability to
take more clients.

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? (SATA)

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

Rationale: Clients with burns, spine injuries, eye injuries, and stable abdominal injuries should be treated within 30
minutes to 2 hours, and therefore should 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

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

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

Rationale: 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 should 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.

A hospital prepares to receive large numbers of casualties from a community disaster. Which clients should the nurse
identify as appropriate for discharge or transfer to another facility? (SATA)

a. Older adult in the medical decision unit for evaluation of chest pain

b. Client who had open reduction and internal fixation of a femur fracture 3 days ago

c. Client admitted last night with community-acquired pneumonia

d. Infant who has a fever of unknown origin

e. Client on the medical unit for wound care

Rationale: The client with the femur fracture could be transferred to a rehabilitation facility, and the client on the medical
unit for wound care should be transferred home with home health or to a long-term care facility for ongoing wound care.
The client in the medical decision unit should be identified for dismissal if diagnostic testing reveals a noncardiac
source of chest pain. The newly admitted client with pneumonia would not be a good choice because culture results are
not yet available and antibiotics have not been administered long enough. The infant does not have a definitive
diagnosis.
A hospital prepares for a mass casualty event. Which functions are correctly paired with the personnel role? (SATA)

a. Paramedic Decides the number, acuity, and resource needs of clients

b. Hospital incident commander Assumes overall leadership for implementing the emergency 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

Rationale: 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.