ABC 123
In completing a primary survey, the nurse assesses which factor to determine the “E” in the ABCDE sequence?
A. Emotion
B. Estimated blood loss
C. Exposure
D. Extremities
C. Exposure
Exposure means to completely undress the patient so that obvious and potential injuries, both front and back, can be quickly identified. With a large trauma team, these assessments of the primary survey can be done simultaneously.
What is the priority in the preparedness of healthcare professionals in any type of disaster plan?
A. Identification of hazards
B. Cooperation with state authorities
C. Collaboration with local authorities
D. Implementation of federal mandates
A. Identification of hazards
Identification of hazards is the priority in the preparedness of healthcare professionals in any type of disaster plan.
What is the goal of triage?
A. Maximize number of survivors
B. Provide lifesaving measures
C. Determine level of care needed
D. Prioritize care needs of all victims
A. Maximize number of survivors
Regardless of the system used, the primary goal of disaster triage is to maximize the number of survivors.
The nurse monitors for which acid–base disorder in the patient with early hypothermia?
A. Metabolic acidosis
B. Metabolic alkalosis
C. Respiratory acidosis
D. Respiratory alkalosis
D. Respiratory alkalosis
Mild hypothermia is when the body’s core temperature is 89.6°F–95°F (32°C–35°C). The human body tries to compensate for decreases in body temperature by stimulating the sympathetic nervous system to shiver and increase heart rate, blood pressure, respirations, and promote peripheral vasoconstriction. Tachypnea causes a decrease in CO2 levels, resulting in a respiratory alkalosis.
Which treatment does the nurse prepare to administer when providing care to a patient who presents after an accidental overdose of Tylenol?
A. Gastric lavage
B. Activated charcoal
C. Peritoneal dialysis
D. Vitamin D injection
B. Activated charcoal
The nurse would prepare to administer activated charcoal to the patient.
After the nurse secures the airway of a trauma patient in the emergency department (ED), what is the next conduct in the primary survey?
A. Assess the patient’s respiratory rate.
B. Monitor the patient’s blood pressure.
C. Assess the patient’s pupillary reaction.
D. Cover the patient with a warm blanket.
A. Assess the patient’s respiratory rate.
Once the patient’s airway is secured, the next step in the primary survey is to monitor the patient’s ventilations and apply high-flow oxygen, if needed.
The nurse is helping devise a training plan to familiarize healthcare providers with emergency response procedures. Which training measure is most effective to adequately prepare the trainees?
A. Drills
B. Tabletop exercises
C. Access to the policy
D. Computer simulations
A. Drills
Hospital disaster drills are priority training measures to familiarize healthcare providers with emergency response procedures.
The nurse responds to a mass casualty event and implements Simple Triage and Rapid Treatment (START) to triage patients. Which patient does the nurse tag as green?
A. The patient who remains apneic after airway repositioning.
B. The patient who begins breathing after airway management is implemented.
C. The patient who is walking, has abrasions, and follows commands appropriately.
D. The breathing patient with a capillary refill of 3 seconds who cannot follow simple direction.
C. The patient who is walking, has abrasions, and follows commands appropriately.
This patient is capable of ambulating, understands directions, and has adequate perfusion to stay upright; therefore, this patient is tagged green or “minor.”
The nurse monitors for which clinical manifestations in the patient diagnosed with heat stroke?
A. Vertigo
B. Red, dry skin
C. Profuse sweating
D. Nausea
B. Red, dry skin
Heat stroke is a medical emergency. The body’s thermoregulatory mechanism has failed, and the body temperature rises uncontrollably. Immediate intervention is necessary to prevent organ damage and death. Classic heatstroke develops over several days during a heat wave and typically affects elderly, sedentary people with preexisting conditions. Patients usually present with red, dry skin; the patient has stopped sweating altogether.
The nurse prepares to administer which medication to treat a patient with acetaminophen overdose?
A. N-acetylcysteine
B. Flumazenil
C. Sodium bicarbonate
D. Glucagon
A. N-acetylcysteine
N-acetylcysteine is given by mouth or intravenously to prevent or minimize hepatotoxicity with acetaminophen toxicity.
Which nursing action is appropriate when conducting a secondary survey during the emergency assessment?
A. Maintaining privacy
B. Having suction available
C. Giving supplemental oxygen
D. Completing a pain assessment
D. Completing a pain assessment
At the beginning of the secondary survey, a complete set of vital signs are obtained, and pain is assessed.
Maintaining privacy, having suction available, and giving supplemental oxygen are all interventions during the primary survey.
What is the highest level of personal protective equipment (PPE) for respiratory protection?
A. Level A
B. Level B
C. Level C
D. Level D
A. Level A
Level A is the highest level of respiratory, eye, mucous membrane, and skin protection. This level provides protection against gas, vapor, liquid, and oxygen-deficient atmospheres.
The nurse conducts triage under mass casualty conditions and assigns which tag to the patient who is experiencing hypovolemic shock as a result of a penetrating wound?
A. Red
B. Black
C. Green
D. Yellow
A. Red
The nurse uses a red tag for a patient who has injuries that are an immediate threat to life, such as hypovolemic shock, during mass casualty conditions.
The first step in the management of a patient being treated for hyperthermia includes which nursing action?
A. Inserting an indwelling catheter
B. Initiating intravenous access
C. Implementing low flow oxygen
D. Relocating to a cool environment
D. Relocating to a cool environment
All interventions for hyperthermia start with removal to a cooler environment and hydration. Heat stress or heat edema may require nothing more than moving to a cooler environment. The patient with heat syncope requires safety maneuvers to help prevent injury from falling. After being gently helped to the floor, the patient should be placed in the recovery position until full recovery of consciousness. Heat cramping requires rehydration with oral fluids containing electrolytes to correct the fluid and electrolyte loss.
The nurse monitors for which initial clinical manifestations in the patient being treated for drowning?
A. Alkalosis
B. Tachycardia
C. Elevated temperature
D. Hypocarbia
B. Tachycardia
Initially, the victim is hypertensive and tachycardic with activation of the sympathetic nervous system.
The nurse cares for a patient in the emergency department with a cervical (C-) spine injury. The patient is unconscious and has a partial airway obstruction from the tongue. SpO2 is 89%. What action should the nurse take first?
A. Call for help.
B. Perform abdominal thrusts.
C. Open the airway using the jaw thrust maneuver.
D. Apply oxygen.
C. Open the airway using the jaw thrust maneuver.
There is always a high index of suspicion for cervical (C-) spine injury after trauma. It is essential to maintain C-spine precautions and use the jaw thrust maneuver when assessing airway and breathing and when placing a definitive airway, if necessary.
What would the nurse working in the emergency department identify as clinical priorities for the treatment of a patient with a gunshot wound? Select all that apply.
A. Airway maintenance
B. Obtaining medical history
C. Ventilation assistance
D. Hemorrhage control
E. Hypothermia prevention
A. Airway maintenance
C. Ventilation assistance
D. Hemorrhage control
E. Hypothermia prevention
This is correct. Clinical priorities for the treatment of gunshot wounds are the following: maintain airway and assist ventilation as necessary, control hemorrhage, and prevent hypothermia. Also necessary is a rapid, recurrent assessment of the patient’s neurological status, as well as prevention of infection.
Based upon Simple Triage and Rapid Treatment (START), the nurse tags the patient with which injury as yellow during the triage process?
A. Ankle sprain
B. Hypovolemic shock
C. Open femur fracture
D. Massive head trauma
C. Open femur fracture
When using a triage tag system, an open femur fracture is an urgent but not life-threatening injury that would be tagged as yellow.
Which statement by the patient about snake bites indicates the need for further teaching?
A. “So I should return immediately if I develop swelling, redness, and an increase in pain.”
B. “If I have dark or bloody urine, I should seek immediate medical attention.”
C. “It’s okay to pick up a snake right after it died.”
D. “I should return if I start vomiting or have shortness of breath.”
C. “It’s okay to pick up a snake right after it died.”
It is not okay to pick up a dead snake— there is a reflexive bite response even after death.
Which action does the nurse take in the management of a patient with a snake bite?
A. Placing a tourniquet above the bite
B. Applying ice to the bite
C. Cleaning the site with soap and water
D. Scrubbing the bite with alcohol
C. Cleaning the site with soap and water
The wound should be cleansed, and the patient should receive tetanus prophylaxis if the immunization is outdated or unknown. It is not recommended to provide antibiotics for snakebites unless the wound is heavily contaminated.
Which are the top priorities when conducting a primary patient survey during the emergency assessment? Select all that apply.
A. Airway
B. Disability
C. Breathing
D. Circulation
E. Cervical spine
A. Airway
E. Cervical spine
This is correct. Airway and stabilization of the cervical spine are the top priorities when conducting a primary patient survey during the emergency assessment. Airway and stabilization of the cervical spine are the top priorities when conducting a primary patient survey during the emergency assessment.
Which nursing actions are appropriate during the primary survey of the emergency assessment process? Select all that apply.
A. Inserting a nasogastric tube
B. Immobilizing the cervical spine
C. Arranging for diagnostic studies
D. Preparing for chest tube insertion
E. Applying direct pressure to a wound
B. Immobilizing the cervical spine
D. Preparing for chest tube insertion
E. Applying direct pressure to a wound
This is correct. The primary survey focuses on airway, breathing, and circulation (ABCs); disability; and exposure or environmental control. It aims to identify life-threatening conditions so that appropriate interventions can be started. Nursing actions that are appropriate during the primary survey include immobilizing the cervical spine, preparing for chest tube insertion, and applying direct pressure to a wound.
Which patient’s injury would receive a black tag by the triage nurse during a mass casualty incident?
A. Concussion
B. Ankle sprain
C. Open femur fracture
D. Full-thickness body burns
D. Full-thickness body burns
A black tag indicates the patient has suffered an extensive injury and is expected, or allowed, to die. Typical examples of black-tagged patients are those with massive head trauma, extensive full-thickness body burns, and high cervical spinal cord injury requiring mechanical ventilation.
Which interventions does the nurse implement when providing care to a patient who is at risk for hypothermia? Select all that apply.
A. Keeping wet clothing on the patient
B. Placing a warming blanket on the patient
C. Infusing warm intravenous fluids to the patient
D. Increasing the temperature in the patient’s room
E. Providing the patient with room-temperature oral fluids
B. Placing a warming blanket on the patient
C. Infusing warm intravenous fluids to the patient
D. Increasing the temperature in the patient’s room
This is correct. Placing a warming blanket on the patient is an intervention that is appropriate for the patient who is at risk for hypothermia. Infusing warmed intravenous fluids is an appropriate intervention for the patient who is at risk for hypothermia. Increasing the temperature in the patient’s room is an appropriate intervention for the patient who is at risk for hypothermia.
The nurse leads a rapid treatment triage situation with multiple victims. Which action should be taken first?
A. Those who are marked green and ambulating should be moved to a safe area.
B. Those who are apneic receive cardiopulmonary resuscitation.
C. Those who are tachypneic or have impaired perfusion are seen immediately.
D. Those tagged yellow are transported to local hospitals.
To help clear the scene, the patients with minor injuries who are ambulatory should be removed.