YOU
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!"
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
3.A victim experiencing airway obstruction
Client needs related to maintaining a patent airway are always the priority. Therefore, the nurse would attend to the victim experiencing airway obstruction first. Care to the other victims follows.
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
3.A young woman who appears dazed and confused and is shivering
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.
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?*
RED
The red tag indicates the patient must be seen first because they have life-threatening injuries, but could survive if treated quickly. The patient is still alive but there is a severe alteration in their breathing, circulation, or mental status that requires immediate medical attention.
The 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
2.
A client with a Holter monitor
3.
A client receiving oral antibiotics
4.
A client experiencing sinus rhythm
Clients should be medically stable if discharged and should be able to manage their condition at home. A client experiencing chest pain could be having a myocardial infarction and needs frequent monitoring. A client newly diagnosed with atrial fibrillation requires medication and monitoring to stabilize the condition. A client in third-degree heart block is considered unstable, especially if the client needs a pacemaker.
If a patient has a blood volume of 5 Liters and loses 2 Liters, what is the percentage amount of volume loss this patient has experienced?
The answer is B. This patient has lost 40% of blood volume. Based on this amount of fluid loss, this patient would be in class III (stage 3 of hypovolemic shock). Class III occurs when volume loss is 30-40% or 1,500-2,000 mL in an adult.
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?*
The answer is B: Red.
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?*
The answer is D: Black. The black tag is placed on the wounded that are dying or have expired. The injuries are so severe that death is imminent. There is severe alteration or absence of breathing, circulation, and neuro status.
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
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
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 client who remains febrile with peritonitis and the client who has continuing rhonchi with heart failure need to be monitored on an ongoing basis. The remaining clients could be cared for at home with the help of a home health care nurse.
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?*
The answer is D: Black.
A patient in hypovolemic shock is receiving rapid infusions of crystalloid fluids. Which patient finding requires immediate nursing action?
The answer is B. When crystalloid fluids are given there is a risk for fluid volume overload even though the patient is hypovolemic, especially with rapid infusions. Therefore, the nurse should monitor the patient for this. If a patient develops difficulty breathing (dyspnea) and has crackles in the lung fields (this represents edema in the lungs), fluid is backing up in the lungs. This requires immediate nursing action. Option A and C are expected finding in hypovolemic shock, and option D is a normal finding...urinary output should be >30 mL/hr.
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?*
GREEN
Green tags are for patients who have MINOR injuries. If the patient can walk around they are tagged as green. Sometimes they are referred to as the “walking wounded”.
You’re making the patient assignments for the next shift. On your unit there are three LPNs, two RNs, and two nursing assistants. Which patients will you assign to the LPNs? Select all that apply:*
Answers are C and D. Option A: An RN is the best for this patient because the patient will need discharge teaching AND the nurse will need to teach the patient how to self-administer antibiotics. Option B: This is a new admission and the patient is UNSTABLE. Most patients with DKA (diabetic ketoacidosis) require insulin drips along with close monitoring of the blood glucose levels, which requires critical thinking and interpretation. Options C and D are best for the LPNs: these are standard routine procedures the LPN can perform and these patient cases are stable.
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
Tertiary level of prevention
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 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?*
The answer is B: Red.
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?*
The answer is B: Red.
Which patients below are best assigned to the LPN?*
Answers are B and C. LPNs should be assigned STABLE patients with predicable outcomes and cases that don’t require critical thinking or complex analysis. The patients in options A and D are unstable and require constant care with decisions being based on how to interpret patient findings.
True or False: Hypovolemic shock occurs where there is low fluid volume in the interstitial compartment.
Answer: FALSE Hypovolemic shock occurs where there is low fluid volume in the INTRAVASCULAR (not interstitial) system.
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
3.Bright red bleeding from a neck wound
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 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?*
The answer is C: Yellow.
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
2.A client experiencing sinus rhythm
3.A client receiving oral anticoagulants
4.A client with chronic atrial fibrillation
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.
B, C, E
A 35-year-old male arrives to the emergency room with multiple long bone fractures and an internal abdominal injury. The patient is anxious. Patient's vital signs are: Blood pressure 70/54, heart rate 125 bpm, respirations 30, oxygen saturation on 2 L nasal cannula 96%, temperature 99.3 'F, pain 6 on 1-10 scale. During assessment it is noted the skin is cool and clammy. The nurse will make it priority to?
The answer is C. This patient is at major risk for hypovolemic shock due to the multiple long bone fractures and an internal abdominal injury (this can lead to relative hypovolemic shock...where fluid is loss inside the body). The patient is already showing signs and symptoms of hypovolemic shock. Therefore, it should be a nursing priority to establish IV access (at least two sites should be obtained using a large-bore cannula....18 gauge or higher). Fluids and possibly blood products will need to be given to this patient along with pain medication etc.
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
1.
Flashlight
2.
Supply of batteries
3.
Battery-operated radio
4.
Extra pair of eyeglasses
Options 1, 2, 3, and 4 should be identified as items to have on hand as part of disaster preparedness. A 3-day supply of water is recommended (1 gallon per client per day). Similarly, a 3-day supply of nonperishable food is recommended. A 4-week supply of water and food is unnecessary and not recommended.
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
A victim experiencing dyspnea
The client experiencing dyspnea is the priority. Needs related to maintaining a patent airway are always the priority. The victims experiencing confusion, tachycardia, and intense pain would be assessed following stabilization of the client with an airway problem.
The wounded victim is able to walk and obey commands. The wounded victim is assigned what tag color?*
The answer is A: Green.
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
A client with crushing substernal pain who is short of breath
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.
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.
1.
Call the nursing supervisor to activate the agency disaster plan.
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.
As the nurse you know that in order for hypovolemic shock to occur the patient would need to lose __________ of their blood volume.
The answer is C. As the nurse you know that in order for hypovolemic shock to occur the patient would need to lose 15% or more of their blood volume.
A patient is 1 hour post-op from abdominal surgery and had lost 20% of their blood volume during surgery. The patient is experiencing signs and symptoms of hypovolemic shock. What position is best for this patient?
The answer is A. Modified Trendelenburg position is where the patient is supine with their legs elevated at 45 degrees. This will help increase venous return to the heart (hence increase preload), which will help increase cardiac output.
One of your patients begins to vomit large amounts of bright red blood. The patient is taking Warfarin. You call a rapid response. Which assessment findings indicate this patient is developing hypovolemic shock? Select all that apply:
The answers are: C, D, E, F, G, and H. Signs and symptoms of hypovolemic shock include: tachycardia, hypotension, increased respiratory rate, cool/pale/clammy skin, anxiety, decreased urinary output (normal UOP is >30 mL/hr), weak peripheral pulses
A patient is receiving large amounts of fluids for aggressive treatment of hypovolemic shock. The nurse makes it PRIORITY to?
The answer is B. It is very important when giving large amount of fluids that the nurse ensures the fluids are warm. WHY? To prevent the patient from developing hypothermia. If this develops, clotting enzymes can become altered along with leukopenia and thrombocytopenia. Keep the patient warm, but not too hot.
A patient who is experiencing hypovolemic shock has decreased cardiac output, which contributes to ineffective tissue perfusion. The decrease in cardiac output occurs due to?
The answer is C. Because there is a major depletion of volume in the intravascular system, there will be a decrease in the amount of venous return to the heart (this is the amount of blood draining back to the heart). Hence, this will lead to a DECREASE in preload. Remember preload is the amount the ventricles stretch once their filled with blood. The ventricle won't be stretching too much because there isn't enough fluid to fill them. This will decrease stroke volume and in turn decrease cardiac output.
. The patient with hypovolemic shock is in need of clotting factors. Which type of fluid would best benefit this patient?
The answer is C. A patient who needs clotting factors would benefit from fresh frozen plasma (FFP).
You're patient is being transported to special procedures for a PICC line placement. The patient is in droplet precautions. What are your nursing actions to ensure proper transport of the patient?*
A
A patient is diagnosed with Hepatitis A and is incontinent of stool. What type of precautions would be initiated?*
A
On your unit there are two RNs: one is a new RN while the other is an experienced RN. In addition, there are three LPNs and two nursing assistants. Which tasks delegated to one of the nursing assistants by the new RN needs to be re-evaluated?*
Answers: A and B Option A is a task for an LPN or RN…hydrocortisone cream is a medication and the nursing assistant can’t administer medications. Option B: is a task for an LPN or RN….it is a procedure. Option C, D, and E are all delegated tasks a nursing assistant can perform.
Select ALL the conditions that warrant airborne precautions:*
C, D, E, T
C
What signs and symptoms in a young infant would alert the nurse that the patient is likely experiencing fluid volume deficit? Select all that apply:(Required)
A. Weight gain
B. Bulging fontanelles
C. Sunken fontanelles
D. No tears when crying
C, D
Which of the following patients would be in contact precautions? Select-all-that-apply:*
A, B, C, D, E, F