NCSBN TEST BANK - for the NCLEX-RN & NCLEX-PN, Updated 2021, Complete Questions & Answers, Exams of Nursing

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Chapter 8: Concepts of Emergency and Trauma Nursing Nursing School Test Banks

1. An emergency room nurse assesses a client who has been raped. With which health care team member should the nurse collaborate when planning this clients care? a. Emergency medicine physician b. Case manager c. Forensic nurse examiner d. Psychiatric crisis nurse ANS: C
2. The emergency department team is performing cardiopulmonary resuscitation on a client when the clients spouse arrives at the emergency department. Which action should the nurse take first? a. Request that the clients spouse sit in the waiting room. b. Ask the spouse if he wishes to be present during the resuscitation. c. Suggest that the spouse begin to pray for the client. d. Refer the clients spouse to the hospitals crisis team. ANS: B
3. An emergency room nurse is triaging victims of a multi-casualty event. Which client should 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 ANS: C
4. While triaging clients in a crowded emergency department, a nurse assesses a client who presents with symptoms of tuberculosis. Which action should 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. ANS: C
5. A nurse is triaging clients in the emergency department (ED). Which client should 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 with a respiratory rate of 28 breaths/min and a temperature of 101 F ANS: B
6. 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 ANS: B
7. Emergency medical technicians arrive at the emergency department with an unresponsive client who has an oxygen mask in place. Which action should 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. ANS: A
8. A trauma client with multiple open wounds is brought to the emergency department in cardiac arrest. Which action should 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. ANS: B

9. A nurse is triaging clients in the emergency department. Which client should 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 d. A 50-year-old male with new-onset confusion and slurred speech ANS: C
10. An emergency department nurse is caring for a client who has died from a suspected homicide. Which action should the nurse take? a. Remove all tubes and wires in preparation for the medical examiner. b. Limit the number of visitors to minimize the familys trauma. c. Consult the bereavement committee to follow up with the grieving family. d. Communicate the clients death to the family in a simple and concrete manner. ANS: D
11. An emergency department (ED) case manager is consulted for a client who is homeless. Which intervention should 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. ANS: C
12. An emergency department nurse is caring for a client who is homeless. Which action should the nurse take to gain the clients trust? a. Speak in a quiet and monotone voice. b. Avoid eye contact with the client. c. Listen to the clients concerns and needs. d. Ask security to store the clients belongings. ANS: C
13. A nurse is triaging clients in the emergency department. Which client should 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 temperature of 104 F ANS: C
14. A nurse is caring for clients in a busy emergency department. Which actions should 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. Isolate clients who have immune suppression disorders to prevent hospital-acquired infections. ANS: B, C, D
15. An emergency department (ED) nurse is preparing to transfer a client to the trauma intensive care unit. Which information should the nurse include in the nurse-to-nurse hand-off report? (Select all that apply.) a. Mechanism of injury b. Diagnostic test results c. Immunizations d. List of home medications

e. Isolation precautions ANS: A, B, E

3. An emergency room nurse is caring for a trauma client. Which interventions should 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 ANS: B, C, E, F
4. The complex care provided during an emergency requires interdisciplinary collaboration. Which interdisciplinary 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 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 immobilization, 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 ANS: A, E
5. A nurse prepares to discharge an older adult client home from the emergency department (ED). Which actions should 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. ANS: D, E Chapter 9: Care of Patients with Common Environmental Emergencies Nursing School Test Banks
6. On a hot humid day, an emergency department nurse is caring for a client who is confused and has these vital signs: temp 104. F (40.1 C), pulse 132 beats/min, respirations 26 breaths/min, blood pressure 106/66 mm Hg. Which action should 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 re-assess in 15 minutes. ANS: B
7. While at a public park, a nurse encounters a person immediately after a bee sting. The persons lips are swollen, and wheezes are audible. Which action should the nurse take first? a. Elevate the site and notify the persons next of kin. b. Remove the stinger with tweezers and encourage rest. c. Administer diphenhydramine (Benadryl) and apply ice. d. Administer an EpiPen from the first aid kit and call
8. ANS: D
9. A client presents to the emergency department after prolonged exposure to the cold. The client is difficult to arouse and speech is incoherent. Which action should the nurse take first? a. Reposition the client into a prone position.

b. Administer warmed intravenous fluids to the client. c. Wrap the clients extremities in warm blankets. d. Initiate extracorporeal rewarming via hemodialysis. ANS: B

4. An emergency department nurse cares for a middle-aged mountain climber who is confused and exhibits bizarre behaviors. After administering oxygen, which priority intervention should the nurse implement? a. Administer dexamethasone (Decadron). b. Complete a minimental state examination. c. Prepare the client for computed tomography of the brain. d. Request a psychiatric consult. ANS: A
5. An emergency department nurse assesses a client admitted after a lightning strike. Which assessment should the nurse complete first? a. Electrocardiogram (ECG) b. Wound inspection c. Creatinine kinase d. Computed tomography of head ANS: A
6. 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. ANS: A
7. A provider prescribes a rewarming bath for a client who presents with partial-thickness frostbite. Which action should 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. ANS: A
8. A nurse assesses a client recently bitten by a coral snake. Which assessment should the nurse complete first? a. Unilateral peripheral swelling b. Clotting times c. Cardiopulmonary status d. Electrocardiogram rhythm ANS: C
9. A nurse plans care for a client admitted with a snakebite to the right leg. With whom should the nurse collaborate? a. The facilitys neurologist b. The poison control center c. The physical therapy department d. A herpetologist (snake specialist) ANS: B
10. 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. Which action should 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. ANS: A

11. A nurse assesses a client admitted with a brown recluse spider bite. Which priority assessment should 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 clients temperature every 4 hours. ANS: D
12. A provider prescribes Crotalidae Polyvalent Immune Fab (CroFab) for a client who is admitted after being bitten by a pit viper snake. Which assessment should the nurse complete prior to administering this medication? a. Assess temperature and for signs of fever. b. Check the clients creatinine kinase level. c. Ask about allergies to pineapple or papaya. d. Inspect the skin for signs of urticaria (hives). ANS: C
13. A provider prescribes diazepam (Valium) to a client who was bitten by a black widow spider. The client asks, What is this medication for? How should 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. ANS: B
14. After teaching a client how to prevent altitude-related illnesses, a nurse assesses the clients understanding. Which statement indicates the client needs additional teaching? a. If my climbing partner cant think straight, we should descend to a lower altitude. b. I will ask my 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. ANS: C
15. A nurse is teaching a wilderness survival class. Which statements should 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 the loss of heat. 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. ANS: A, D, E
16. A nurse teaches a client who has severe allergies to prevent bug bites. Which statements should the nurse include in this clients 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 auto-injector in a bedside drawer. e. Use screens in your windows and doors to prevent flying insects from entering. ANS: A, B, E
17. A nurse is providing health education at a community center. Which instructions should 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. ANS: A, C, D, F

4. An emergency department nurse moves to a new city where heat-related illnesses are common. Which clients does the nurse anticipate being at higher risk for heat-related illnesses? (Select all that apply.) a. Homeless individuals b. Illicit drug users c. White people d. Hockey players e. Older adults ANS: A, B, E
5. An emergency department nurse plans care for a client who is admitted with heat stroke. Which interventions should the nurse include in this clients 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. d. Infuse 0.9% sodium chloride via a large-bore intravenous cannula. e. Obtain baseline serum electrolytes and cardiac enzymes. ANS: A, D, E Chapter 10: Concepts of Emergency and Disaster Preparedness Nursing School Test Banks
6. 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. ANS: A
7. 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 should 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 youd like. ANS: D
8. A nurse is field-triaging clients after an industrial accident. Which client condition should 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 ANS: D
9. 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. ANS: D
10. The hospital administration arranges for critical incident stress debriefing for the staff after a mass casualty incident. Which statement by the debriefing team leader is most appropriate for this situation? a. You are free to express your feelings; whatever is said here stays here. b. Lets evaluate what went wrong and develop policies for future incidents.

c. This session is only for nursing and medical staff, not for ancillary personnel. d. Lets pass around the written policy compliance form for everyone. ANS: A

6. A nurse is caring for a client whose wife died in a recent mass casualty accident. The client says, I cant believe that my wife is gone and I am left to raise my children all by myself. How should 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. ANS: C
7. A nurse cares for clients during a community-wide disaster drill. Once of the clients asks, Why are the individuals with black tags not receiving any care? How should 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. ANS: C
8. A nurse wants to become involved in community disaster preparedness and is interested in helping set up and staff first aid stations or community acute care centers in the event of a disaster. Which organization is the best fit for this nurses interests? a. The Medical Reserve Corps b. The National Guard c. The health department d. A Disaster Medical Assistance Team ANS: A
9. A nurse wants to become part of a Disaster Medical Assistance 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 governments priority concern. d. If you are deployed, you will be issued a temporary license in the state in which you are working. ANS: A
10. After a hospitals 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 should 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? ANS: B
11. A family in the emergency department is overwhelmed at the loss of several family members due to a shooting incident in the community. Which intervention should the nurse complete first? a. Provide a calm location for the family to cope and discuss needs. b. Call the hospital chaplain to stay with the family and pray for the deceased. c. Do not allow visiting of the victims until the bodies are prepared. d. Provide privacy for law enforcement to interview the family. ANS: A
12. An emergency department charge nurse notes an increase in sick calls and bickering among the staff after a week with multiple trauma incidents. Which action should the nurse take? a. Organize a pizza party for each shift. b. Remind the staff of the facilitys sick-leave policy. c. Arrange for critical incident stress debriefing.

d. Talk individually with staff members. ANS: C

1. 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 ANS: A, C, D, F
2. 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 ANS: A, D
3. 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? (Select all that apply.) 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 ANS: B, E
4. 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 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 ANS: B, D LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Chapter 11 Question 1 A patient is brought to the emergency department with injuries sustained in a motor vehicle crash. What should the nurse consider as the cause of this patient’s injuries?
5. trauma
6. not wearing a seat restraint
7. a drunk driver
8. not paying attention while driving Correct Answer: 1 Question 2 The spouse of a patient admitted with a gunshot wound asks the nurse when her husband will be discharged so that they can resume their life together. How should the nurse respond?
9. “Right now there is no way of knowing how soon your husband can return to his previous life.”
10. “I would say in a few weeks.”
11. “Probably never.”
12. “As soon as the wound heals, your husband can return to work.” Correct Answer: 1

Question 3 An older patient is admitted after falling on the steps at home. Which components of trauma should the nurse consider when planning care for the patient? Select all that apply.

1. host
2. environment
3. intention
4. source
5. transmission Correct Answer: 1, 2, 3 Question 4 A patient comes into the emergency department with leg pain after falling on ice. For which classification of injuries should the nurse expect to plan care for this patient?
6. Class 3 minor
7. Class 1 minor
8. Class 1 penetrating
9. Class 3 penetrating Correct Answer: 1 Question 5 A patient is brought to the emergency department with injuries sustained when a wall collapsed in the home. The nurse recognizes that this patient’s injuries were most likely caused by which mechanism of injury?
10. crushing
11. shearing
12. deceleration
13. blast Correct Answer: 1 Question 6 A patient was admitted with a head injury caused by rapid acceleration and deceleration. How should the nurse expect this patient’s injuries to be classified?
14. blunt
15. shearing
16. blast
17. minor Correct Answer: 1 Question 7 A patient is admitted with a thermal injury. Which mechanism of injury should the nurse consider as the most likely cause of this patient’s injuries?
18. fire
19. lightning
20. ultraviolet radiation
21. gunshot Correct Answer: 1 Question 8 A pediatric patient is admitted after ingesting a household cleaning solution. The nurse should plan care for this patient’s injuries based on which energy source?
22. chemical
23. physical
24. thermal
25. mechanical Correct Answer: 1 Question 9

A patient recovering from a motor vehicle accident tells the nurse that the other car “barely” hit him and asks why he has so many injuries. How should the nurse respond?

1. “The car that hit you transferred a large amount of energy to your body, causing these injuries.”
2. “You have other health problems that make the injuries worse.”
3. “The driver of the other car intended to hit you.”
4. “Because you are older, your injuries will be worse.” Correct Answer: 1 Question 10 A construction worker was admitted after falling from the roof of a building. The nurse should plan care for this patient’s injuries based on which energy source?
5. gravitational
6. mechanical
7. physical
8. electrical Correct Answer: 1 Question 11 A patient is admitted to the hospital with injuries from a motor vehicle crash. During the nurse’s initial assessment, the patient develops hypotension and severe jugular distension with a tracheal deviation. What should the nurse suspect is occurring in this pt?
9. tension pneumothorax
10. hemorrhage
11. compensatory shock
12. hypovolemic shock Correct Answer: 1 Question 12 A patient is admitted with a diagnosis of blunt trauma to the abdomen after a motor vehicle crash. What should the nurse assess first when the patient arrives in the emergency department?
13. airway for patency
14. abdomen for any abnormalities
15. cervical spine for tenderness
16. signs of neurological deficits Correct Answer: 1 Question 13 A patient is brought to the emergency department with a penetrating wound to the neck. The patient is dyspneic and cyanotic and has evidence of subcutaneous emphysema. What does the nurse expect the physician to do initially?
17. intubate the patient because of the severe wound
18. notify the next of kin regarding the patient’s condition
19. order x-rays of the lumbar area to assess for fractures
20. administer a beta blocker to alleviate the sympathetic response Correct Answer: 1 Question 14 The nurse suspects that a patient who was in a motor vehicle crash does not have a cervical spine injury. What did the nurse assess to come to this conclusion?
21. alert without midline cervical tenderness
22. lacking motor response in lower extremities
23. lacking deep tendon reflexes
24. lethargic and confused Correct Answer: 1 Question 15 A patient is brought to the emergency department with physical injuries sustained in a gang fight. The patient’s blood pressure is 80/ mmHg, with a pulse of 120 and thready. Which diagnostic test should the nurse expect to be performed to provide the fastest information?
25. sonogram

2. complete blood count
3. urinalysis
4. serum electrolyte levels Correct Answer: 1 Question 16 A patient is admitted with possible head and spinal cord injuries sustained after falling from a ladder. Which diagnostic test should the nurse expect to be prescribed that will identify the type and extent of this patient’s injuries?
5. magnetic resonance imaging
6. cervical spine x-rays
7. spinal cord x-rays
8. cerebral angiogram Correct Answer: 1 Question 17 A victim of a multivehicle automobile crash is brought into the emergency department. The patient has slurred speech and is lethargic. The nurse anticipates that which diagnostic tests would be indicated for this patient? Standard Text: Select all that apply.
9. blood alcohol level
10. urine drug screen
11. skull x-rays
12. chest x-ray
13. urinalysis Correct Answer: 1, 2 Question 18 The nurse determines that a patient is experiencing ongoing progression of a shock state. What finding led the nurse to come to this conclusion?
14. decrease in serum glucose level
15. drop in blood urea nitrogen level
16. increased eosinophil level
17. low serum cardiac enzyme level Correct Answer: 1 Question 19 A patient with multiple traumatic injuries has experienced severe blood loss and is prescribed to receive blood immediately. The nurse realizes that because there is not enough time for type and crossmatch, the patient will most likely receive which type of blood?
18. O
19. A
20. B
21. AB Correct Answer: 1 Question 20 A patient with multiple gunshot wounds to the abdomen has received 8 units of blood. The blood bank notifies the nurse that they have run out of blood for the patient. The nurse knows the patient can receive any type of blood if the patient has which blood type?
22. AB
23. A
24. B
25. O Correct Answer: 1 Question 21 A patient admitted with multiple injuries is prescribed an intravenous colloid solution. Which solution would be appropriate for the nurse to infuse?
26. 25% albumin
27. 0.9% normal saline
28. dextrose 5% and 0.45 % normal saline

4. dextrose 5% and water Correct Answer: 1 Question 22 A patient diagnosed with hypovolemic shock is prescribed intravenous fluids while awaiting blood transfusions. Which solution does the nurse recognize would be best for this patient?
5. Ringer’s lactate
6. Dextrose 5% and water
7. Dextrose 5% and 0.45% normal saline
8. Dextrose 5% and 0.9% normal saline Correct Answer: 1 Question 23 A patient diagnosed with shock is prescribed dobutamine (Dobutrex). Which finding indicates this medication has been effective?
9. increased heart rate
10. reduced heart rate
11. decreased respiratory rate
12. decreased blood pressure Correct Answer: 1 Question 24 The nurse is preparing to administer intravenous nitroglycerin to a patient diagnosed with cardiogenic shock. What should the nurse do when administering this medication?
13. Use an infusion pump.
14. Administer with PVC tubing.
15. Use within 8 hours of reconstitution.
16. Allow the patient to get out of bed only with assistance. Correct Answer: 1 Question 25 A patient with a traumatic brain injury is being evaluated for brain death. Which findings should the nurse expect in this patient? Select all that apply.
17. absence of gag or corneal reflex
18. absence of oculovestibular reflex
19. apnea with^ PaCO 2 of 66^ mmHg
20. toxic metabolic disorders
21. response to deep stimuli Correct Answer: 1,2, Question 26 The spouse of a patient admitted with severe head injury tells the nurse that she believes her husband is going to recover because he is continuing to make movements without stimulation. What should the nurse explain to the spouse?
22. “With head injuries, the patient can continue to make movements, but these are reflexes that do not reflect brain function.”
23. “Your husband will likely recover in time.”
24. “As long as he has oxygen to the brain, he will recover.”
25. “His movements indicate that his brain is dead.” Correct Answer: 1 Question 27 A patient is brought to the emergency department with gunshot wounds to the abdomen and lower extremities. To protect the chain of evidence for these injuries, what should the nurse do?
26. Remove the patient’s clothing and place in a breathable bag.
27. Cover the patient’s hands with plastic bags.
28. Cut off the patient’s clothing and bathe the skin and wounds as soon as possible.
29. Place clothing and other patient items on a bedside table and have a nursing assistant remove them when possible. Correct Answer: 1 Question 28

An adult patient who has died from traumatic injuries is an organ donor. What should the nurse do when caring for this patient?

1. Maintain systolic blood pressure of 90 mmHg.
2. Keep oxygen saturation level at 75%.
3. Administer intravenous fluids to maintain a urine output of 25 mL per hour.
4. Perform external cardiac compressions to achieve a heart rate of 60 beats per minute. Correct Answer: 1 Question 29 A patient with traumatic injuries has lost approximately 300 mL of blood. What should the nurse expect to assess in this patient?
5. slight increase in heart rate
6. nonpalpable peripheral pulses
7. narrowing pulse pressure
8. increase in blood glucose level Correct Answer: 1 Question 30 The nurse wants to calculate a patient’s mean arterial pressure. Which vital sign measurement should the nurse use to make this calculation?
9. blood pressure
10. temperature
11. respirations
12. heart rate Correct Answer: 1 Question 31 The nurse is providing medications to increase a patient’s systemic vascular resistance. At which point will the nurse know that the patient has adequate tissue perfusion?
13. Mean arterial pressure reaches 60.
14. Mean arterial pressure reaches 90.
15. Blood pressure reaches 120/80 mmHg.
16. Urine output is 10 mL per hour. Correct Answer: 1 Question 32 A patient has an estimated blood loss of 2 liters and a mean arterial pressure ranging between 30 and 40 mmHg. If this patient’s hemodynamic status is not corrected, what should the nurse realize can occur?
17. failure of sodium-potassium pump
18. cells shrinking
19. full and bounding peripheral pulses
20. metabolic alkalosis Correct Answer: 1 Question 33 The nurse, caring for a patient who sustained a traumatic injury several days ago, notes that the patient is hypotensive, oliguric, and has cool, pale skin and acidosis. The nurse understands that these are manifestations of which type of shock?
21. hypovolemic
22. cardiogenic
23. septic
24. anaphylactic Correct Answer: 1 Question 34 The nurse suspects that a patient diagnosed with a myocardial infarction is developing cardiogenic shock. What manifestation did the nurse assess to come to this conclusion?
25. jugular vein distention
26. warm extremities
27. laryngospasm
28. urticaria

Correct Answer: 1 Question 35 A patient is diagnosed with a pneumothorax. The nurse realizes that unless this is treated, the patient is at risk for developing which type of shock?

1. obstructive
2. hypovolemic
3. cardiogenic
4. neurogenic Correct Answer: 1 Question 36 An older patient is diagnosed with E. coli in the bloodstream. If not treated, the nurse realizes this patient is at risk for developing which types of shock?
5. distributive
6. obstructive
7. hypovolemic
8. anaphylactic Correct Answer: 1 Question 37 A patient is admitted with severe facial injuries from a motor vehicle crash. For what should the nurse first assess this patient?
9. signs of stridor, cough, or respiratory distress
10. blood pressure
11. need for suctioning
12. loose teeth or obvious problems with the mouth Correct Answer: 1 Question 38 A female who was a victim of rape 6 months ago comes to an outpatient clinic for the treatment of posttraumatic stress disorder. Which data collected during the patient’s assessment indicates a manifestation associated with this disorder?
13. The patient described severe nightmares related to the event.
14. The patient denied anger or shock.
15. The patient denied the need for drug or alcohol counseling.
16. The patient stated that her family is very supportive. Correct Answer: 1 Question 39 The nurse is planning care for a patient diagnosed with shock. Which intervention should the nurse include to address this patient’s problem of anxiety?
17. reducing stimuli and medicating for pain
18. assessing blood pressure and heart rate
19. monitoring central venous pressure
20. assessing bowel sounds Correct Answer: 1 Question 40 The nurse identifies the problem of impaired physical mobility in a patient hospitalized with traumatic injuries. Which intervention should the nurse identify as appropriate for this patient?
21. Provide active range-of-motion exercises to affected extremities every 8 hours.
22. Turn and reposition every hour.
23. Remove anti-embolic stockings for 3 hours every shift.
24. Administer tetanus toxoid. Correct Answer: 1 Question 41 A patient is admitted with trauma to the integumentary system. Which type of skin trauma should the nurse prepare to assess? Select all that apply.

1. cutaneous
2. abrasion
3. laceration
4. contusion
5. keloid Correct Answer: 2, 3, 4 Question 42 A trauma patient is being assessed with the Champion Revised Scoring System. What assessment data should the nurse use with this scoring system? Standard Text: Select all that apply.
6. diastolic blood pressure
7. heart rate
8. Glasgow coma scale
9. systolic blood pressure
10. respiratory rate Correct Answer: 3, 4, 5 Question 43 A patient comes to the emergency department with bright red blood flowing from the lower right arm. Place an “X” over the artery over which pressure would be applied to control the bleeding. Correct Answer: Question 44 During shock, the reticuloendothelial Kupffer cells can be destroyed. In which organ should the nurse identify the location of these cells? Place an “X” on the location of these cells. Correct Answer: Rationale: During shock, the blood supply to the liver is impaired because of constriction of the blood supply to the liver. The Kupffer cells (phagocytes that destroy bacteria) are destroyed, and bacteria can proliferate. Global Rationale:

Question 45 The nurse is reviewing data for a patient experiencing shock. Based on these data, the nurse recognizes that the patient is in which stage of shock?

1. compensatory
2. early, reversible
3. progressive
4. refractory Correct Answer: 3 Question 46 The nurse is reviewing the laboratory results for a patient with trauma. Based on this information, what care should the nurse plan for this patient?
5. fluids for distributive shock
6. nothing, because the results are normal
7. contact precautions
8. central venous catheter insertion Correct Answer: 2 Question 47 A patient is to receive nitroglycerin (Tridil) 10 mcg/min. The medication strength is 50 mg/250 mL. The IV rate should be mL/min. Correct Answer: 3 Question 48 A patient has received 145 mL of blood and complains of chills. For what should the nurse assess this patient? Select all that apply.
9. bradypnea
10. urticaria
11. fever
12. hypertension
13. lumbar pain Correct Answer: 2, 3, 5 Question 49 A patient in hypovolemic shock is receiving an intravenous colloid solution (plasma expander). Which assessment findings indicate to the nurse that the infusion rate should be reduced? Select all that apply.
14. prothrombin time of 13.5 seconds
15. jugular vein distention
16. tenting of the skin
17. increased central venous pressure
18. auscultation of crackles and wheezes Correct Answer: 2,4, Question 50 Emergency personnel are preparing to complete an on-the-scene rapid assessment of a victim of a motor vehicle crash. In which order should the victim’s assessment be completed? Place the assessments in order of importance.

1. assessment for obvious injuries
2. Champion Revised Trauma Scoring System
3. airway and breathing assessment
4. circulation assessment
5. level of consciousness and pupillary function Correct Answer: 3, 4, 5, 1, 2 Question 51 A patient receiving a unit of packed red blood cells for hypovolemic shock is demonstrating signs of a transfusion reaction. In which order should the nurse provide care to this patient? 1: Stop the transfusion and notify the physician 2: Compare the blood slip with the unit of blood 3: Assess vital signs and associated manifestations 4: Save the blood bag and tubing for laboratory analysis 5: Collect urine and venous blood samples according to policy Correct Answer: 1, 3, 2, 4, 5 Question 52 The nurse is concerned that a patient with traumatic chest injures is developing respiratory distress. What assessment findings led the nurse to come to this conclusion? Select all that apply.
6. combative behavior
7. absent breath sounds in left lower lobe
8. pedal and popliteal pulses weak and irregular
9. temperature raised 2 degrees over the last 4 hours
10. oxygen saturation 86% on 40% oxygen face mask Correct Answer: 1, 2, 5 Question 53 An older patient with an infected stage IV pressure ulcer is lethargic. What additional findings should the nurse expect to assess in this stage of septic shock? Select all
11. warm, flushed skin
12. urine output 10 mL/hr
13. blood pressure 88/54 mmHg
14. heart rate 118 beats per minute
15. respiratory rate 28 per minute and shallow Correct Answer: 2, 3, 4, 5 Question 54 An adolescent is experiencing anaphylactic shock after being stung by a swarm of bees. Which medications should the nurse anticipate being provided to this patient? Select all that apply.
16. diuretics
17. antibiotics
18. epinephrine
19. beta2-agonist
20. antihistamine Correct Answer: 3, 4, 5 Question 55 A patient with thoracic injuries sustained in a multivehicle crash is demonstrating an alteration in perfusion. What should the nurse do to help this patient? Select all that apply.
21. Auscultate lung sounds.
22. Measure blood pressure.
23. Measure central venous pressure.
24. Reduce rate of intravenous fluids.
25. Assess for jugular vein distention. Correct Answer: 1, 2, 3, 5 Chapter 7

Question 1 A school bus transporting a local university’s basketball team has just crashed in the rain on the side of the road. The bus was transporting approximately 60 people. Which classification should the nurse use to describe the situation?

1. multiple-casualty incident
2. natural disaster
3. human-generated disaster
4. mass-casualty incident Correct Answer: 1 Question 2 The nurse is caring for a patient with injuries received in an earthquake. Which type of incident should the nurse identify as causing this patient’s injuries?
5. natural disaster
6. human-generated disaster
7. emergency
8. multiple-casualty incident Correct Answer: 1 Question 3 A small commuter plane lost an engine and crashed into a shopping mall. The estimated number of injured people from this accident is
9. Which classification of incident should the nurse use when determining the care needed for these victims?
10. mass-casualty incident
11. multiple-casualty incident
12. accidental natural disaster
13. intentional human-generated disaster Correct Answer: 1 Question 4 A train derailed in a local community. The contents of the train caused a hazardous spill, and noxious gasses are being released into the environment. All local and surrounding fire control and Hazmat teams have been mobilized and the event is considered under control. Which type of situation should the nurse prepare for?
14. emergency
15. disaster
16. human-generated accidental disaster
17. intentional emergency Correct Answer: 1 Question 5 The nurse is caring for patients when a dirty bomb detonates at a nearby shopping mall. Which types of injuries should the nurse expect to see in the victims?
18. radiation sickness
19. fractured limbs and spinal injury
20. thermal burns
21. overexertion and exhaustion Correct Answer: 1 Question 6 Several patients are admitted after being exposed to a substance that was released in their manufacturing plant. The patients are demonstrating flu-like symptoms, unproductive cough, and fever. These patients should be assessed for which type of exposure?
22. anthrax
23. smallpox
24. dirty bomb
25. nuclear detonation Correct Answer: 1 Question 7 The nurse is caring for a patient who was brought into the emergency department after an explosion at a nuclear power plant. The patient is confused and keeps repeating that his skin is “on fire.” What does this information indicate to the nurse?

1. The patient may not recover.
2. The patient’s clothing is burning his skin.
3. There is gastrointestinal system involvement and the patient will survive if he receives fluids.
4. There is bone marrow damage and the patient needs oxygen for the confusion. Correct Answer: 1 Question 8 A patient is brought into the emergency department complaining of blindness after an explosion at an atomic power plant. What should the nurse explain to this patient?
5. “The effects of the blast will disappear with time.”
6. “I’m afraid the blast has caused permanent blindness.”
7. “I will contact Social Services so that resources can be identified to help you with your disability.”
8. “There is a variety of resources available for those who are unable to see.” Correct Answer: 1 Question 9 The nurse is caring for a patient who experienced a blast injury to the eye. Which intervention would be appropriate?
9. Flush the eye with eyewash.
10. Encourage the patient to rub the eye to get out specks of dust.
11. Apply a warm compress to the eye.
12. Remove debris lodged in the eye. Correct Answer: 1 Question 10 The nurse is admitting the second patient in 2 days who is experiencing malaise, high fever, and headache. Both patients attended a local air show the previous weekend. What should the nurse do?
13. Discuss the need to contact public health authorities regarding the similarity of the cases.
14. Plan to place the patients in the same room.
15. Ask the patients for permission to talk with family members regarding other symptoms.
16. Assess the patients for what foods they ate while at the air show. Correct Answer: 1 Question 11 An individual arrives at the emergency department with injuries sustained in a natural gas explosion. The patient is unable to respond to questions and keeps repeating “I can’t hear.” For what should the nurse assess this patient?
17. tympanic membrane rupture
18. air embolism
19. oxygen saturation level
20. confusion Correct Answer: 1 Question 12 A victim of a chemical plant explosion is unconscious and brought into the emergency department. For what should the nurse assess this patient?
21. central nervous system injury
22. respiratory system injury
23. pulmonary emboli
24. radiation sickness Correct Answer: 1 Question 13 Two school buses carrying 75 children each collide en route to an out-of-state field trip. The emergency department nurse knows that reverse triage will need to be instituted. What principles should the nurse follow when implementing reverse triage? Select all that
25. When there is a mass casualty event with more than 100 victims, reverse triage may be instituted.
26. Reverse triage works on the principle of the greatest good for the greatest number.
27. A very basic reverse triage system is to categorize or label victims needing the most support and emergency care as red, so they can be treated first.
28. Victims most likely to survive are color-coded black, and are treated first.

5. Reverse triage works on the principle of the greatest good for the most critically ill. Correct Answer: 1, Question 14 A serious highway accident on a foggy night involves 22 vehicles. Several of the victims are ambulatory. The emergency personnel determine that their injuries are minor and arrange for transportation home. Why are these victims triaged first?
6. To do the greatest good for the greatest number of people
7. To remove them so they do not see the critically injured victims
8. To secure the site in case the vehicles become overheated and ignite
9. To improve traffic conditions to clear the accident site quickly Correct Answer: 1 Question 15 Emergency response personnel arrive at the site of a collapsed building. Some victims are walking away from the building, while others are lying on the ground around the perimeter. If implementing reverse triage, what should the emergency personnel do first?
10. Identify one safe location for all ambulatory victims to be assessed and observed.
11. Systematically assess each victim lying on the ground and assign a color.
12. Enter the building to locate other victims who might not have been able to leave before the collapse.
13. Transfer the victims on the ground to stretchers and send them to the local emergency department. Correct Answer: 1 Question 16 A victim of a plane crash exits the plane and runs to an emergency provider to tell him that his mother is trapped inside and is unable to walk out on her own. What should the emergency provider do?
14. Assist with clearing all the victims who are ambulatory first, then locate the trapped victim.
15. Enter the plane to locate the trapped victim.
16. Tell the victim’s son that his mother will be fine and will be removed from the plane as soon as possible.
17. Tell the victim to go back inside and try to get his mother on her feet. Correct Answer: 1 Question 17 The nurse arrives at the site of a bombed building. When preparing to triage victims, in which zone should the nurse conduct decontamination?
18. warm
19. hot
20. cold
21. green Correct Answer: 1 Question 18 Emergency response personnel are wearing gowns, gloves, goggles, and masks. In which decontamination zone are these personnel most likely working?
22. hot
23. warm
24. cold
25. yellow Correct Answer: 1 Question 19 Several victims of a suspected biologic attack are brought into the emergency department. Which type of personal protective equipment should be provided to these victims?
26. mask
27. gown
28. gloves
29. goggles Correct Answer: 1 Question 20

The nurse is assessing victims of a building collapse. Ambulances are nearby and a shelter has been set up with carts, chairs, tables, and refreshments for the victims. The nurse is most likely working within which decontamination zone?

1. cold
2. warm
3. control
4. hot Correct Answer: 1 Question 21 The nurse is reviewing the stages and phases of a disaster as part of a continuing education program in the hospital. In which order should the nurse list the stages of disaster management?
5. Preparedness, mitigation, response, recovery, and evaluation
6. Mitigation, preparedness, response, recovery, and evaluation
7. Mitigation, response, recovery, preparedness, and evaluation
8. Response, mitigation, evaluation, recovery, preparedness Correct Answer: 1 Question 22 The nurse is planning a program to address disaster mitigation activities in the community. What should the nurse consult when preparing this program?
9. community disaster preparedness plan
10. hospital administrators
11. physicians with practices in the community
12. schools and day care centers Correct Answer: 1 Question 23 The nurse is presenting a program to residents of a local senior citizen housing facility about preparations in the event of a disaster. What should the nurse instruct the participants to do regarding essential preparations?
13. Have a list of medications, emergency contact numbers, and necessary survival items readily available.
14. Turn off all electrical devices before leaving the premises.
15. Pack enough nonperishable food items to last for several days.
16. Bring recreational items such as puzzles and card games for entertainment. Correct Answer: 1 Question 24 A group of nurses are attending a meeting to discuss the outcome and results of care provided to victims of a recent building collapse. In which phase of the disaster planning process are the nurses participating?
17. evaluation
18. recovery
19. restoration
20. response Correct Answer: 1 Question 25 The nurse is planning to attend a program to learn how to respond to mass casualty incidents. Which core competencies should the nurse expect to learn during this program? Select all that apply.
21. risk reduction, disease prevention, and health promotion
22. nursing process
23. policy development and planning
24. community care
25. ethical and legal practice Correct Answer: 1,3,4,5 Question 26 The hospital has been notified of a subway derailment involving approximately 250 passengers. Many of the passengers are reported to be injured. For which type of situation should the emergency department manager prepare?
26. a natural disaster

2. a multiple-casualty incident
3. a mass-casualty incident
4. an accidental disaster Correct Answer: 3 Question 27 The care area has been alerted to a possible illness associated with the tainting of a popular over-the-counter pain reliever. The nurse realizes the tainting of this product is what kind of event?
5. a nonconventional terrorist attack
6. a conventional terrorist attack
7. an accidental disaster
8. a natural disaster Correct Answer: 1 Question 28 The emergency department nurses are noting an unusually high number of patients coming in with complaints of nausea, vomiting, and severe headache. What should be done with this information?
9. No further action is needed at this time.
10. Contact the Infection Control Department and Laboratory Medicine.
11. Close the emergency department.
12. Call for more staffing to handle all the patients. Correct Answer: 2 Question 29 A patient comes into the clinic with the onset of itching after opening a letter received about a week ago that contained “quite a bit of white powder.” It is suspected that this patient has had an anthrax exposure. Which medication can the nurse anticipate will most likely be prescribed for this patient?
13. normal saline solution flush to the skin
14. ciprofloxacin (Cipro)
15. acetaminophen
16. Solu-Medrol Correct Answer: 2 Question 30 A patient says to the nurse, “I’m scared about a terrorist attack because I live so close to the airport.” What should the nurse respond to the patient?
17. “Have you thought about moving?”
18. “That’s silly to be so worried.”
19. “What do you have in your home to help you in the event of a terrorist attack?”
20. “I would be concerned, too.” Correct Answer: 3 Question 31 The nursing staff is planning to attend a presentation on disaster prevention. What should the nurse expect the purpose of this education to be?
21. to learn the organization’s disaster plan
22. to have the nurses participate in the plan for handling a disaster
23. to educate the nurses in how to recognize possible terrorists
24. to learn how the nurse will participate in mitigation Correct Answer: 4 Question 32 The community is holding a memorial service to honor members whose lives were lost in a flood one year ago. In which stage of the disaster recovery process is this community?
25. restoration
26. reconstitution
27. mitigation
28. disaster reflection

Correct Answer: 2 Question 33 During a disaster preparedness presentation, the nurse learns about the harmful effects of a dirty bomb. Which treatment should the nurse realize will preserve life in the event of this disaster?

1. support for the patient who will develop radiation sickness
2. heart-lung transplant
3. liver transplant
4. bone marrow transplant Correct Answer: 4 Question 34 A patient is brought into the emergency department with chemical burns. What should the nurse do to help this patient?
5. Check to see if all clothing has been removed and begin flushing the patient’s skin with water.
6. Begin flushing the patient’s clothes and skin with warm water.
7. Do not remove any jewelry.
8. Keep the patient’s contact lenses in place and flush only with warm water. Correct Answer: 1 Question 35 The National Weather Service has announced the likelihood of a large snow event in a major metropolitan area. For which type of health problem should the nurses in the emergency department prepare?
9. stress-related injuries
10. crushing injuries
11. myocardial infarctions
12. burns Correct Answer: 3 Question 36 The emergency response team is setting up an area in which to triage victims of a building blast in a major metropolitan area. Which area should the nurse identify to set up this triage location?
13. hot zone
14. warm zone
15. cold zone
16. clean zone Correct Answer: 3 Question 37 The nurse is planning the coding for a triage disaster plan. Which colors should the nurse use for this plan? Select all that apply.
17. white
18. red
19. yellow
20. black
21. green Correct Answer: 2,3,4,5 Question 38 A woman arrives at the site of a disaster, hysterically crying because she was in the building that collapsed just minutes earlier. What should the nurse do with this patient?
22. Advise her to go home and be with her family.
23. Triage the patient and transport her to the hospital.
24. Have a nurse talk with the patient.
25. Ask psychiatric service personnel to talk with this patient. Correct Answer: 4 Question 39 An older patient asks the nurse, “What can we do to be prepared if there’s a disaster in our community?” How should the nurse respond?

1. “There is not really much we can do to be prepared.”
2. “Plan to evacuate your home at a moment’s notice.”
3. “Make sure all your important papers, health information, medication information, and next-of-kin information is in one place.”
4. “Make sure you can call your family to come and pick you up if this happens.” Correct Answer: 3 Question 40 A mass casualty accident has occurred. The nurse in the emergency department receives a patient who is coded red. What care should the nurse prepare to provide to this patient?
5. Send the patient home.
6. Evaluate the patient in the next few hours.
7. Immediately evaluate this patient.
8. Permit the family to be with the patient as death approaches. Correct Answer: 3 Question 41 A patient with a confirmed diagnosis of anthrax is prescribed ciprofloxacin 500 mg to be administered intravenously over 60 minutes. The pharmacy provides a 1-gram vial of Cipro to the nursing unit to be diluted with 10 mL of sodium chloride. How many mL of the medication should the nurse give to the patient? Correct Answer: 4 Question 42 After an anthrax exposure, the healthcare provider orders doxycycline 100 mg po. The label on the bottle of doxycycline powder states it is to be reconstituted with sterile water to prepare a concentration or 0.025 g/5 mL. The nurse should prepare to administer mL to the patient. Correct Answer: 20 Question 43 Utilizing the simple triage and rapid transport (START) system, in what order should the nurse prioritize the following patients? Choice 1. A 67-year-old male complaining of chest pain. His heart rate is 120 beats/minute, his blood pressure is 100/68 mmHg, and his respiratory rate is 20 breaths/min. Choice 2. A 27-year-old woman presenting with a respiratory rate of 36 breaths/min and capillary refill of 4 seconds. Choice 3. A 58-year-old woman who is able to walk on her own and states over and over, “I don’t know what happened.” Choice 4. A 30-year-old male with a collapsed airway and multiple chest trauma. He does not have a palpable carotid pulse and the nurse is unable to assess respiratory movement. Correct Answer: 2,1,3,4 Question 44 There is a radiologic dispersion bomb (dirty bomb) explosion in a subway station. In what order should the nurse deliver patient care at the scene of the explosion? Choice 1. Begin direct patient care for complaints of fatigue and nausea. Choice 2. Decontaminate clothing of patients. Choice 3. Assess patients for burns and blunt trauma. Choice 4. Evacuate patients from the exposure area. Correct Answer: 3, 4, 2, 1 Question 45 The nurse in the emergency department notes that several patients are demonstrating illness patterns that could indicate an unusual infectious disease process. What did the nurse assess that indicates a possible biological infection in these patients? Select all that
9. Patients present with symptoms of a rare disease.
10. The disease pattern is inconsistent with the age of the patient.
11. Multiple patients are presenting with viral-like symptoms.
12. The patients are all coming from the same geographic area.
13. Patients are all over the age of 39, indicating a smallpox exposure. Correct Answer: 1,2,4 Question 46

Emergency medical personnel are at the scene of a mass casualty incident. What information should personnel document about each victim? Select all that apply.

1. Name and injuries
2. Medication history
3. Interventions performed
4. Allergies
5. Name of next of kin Correct Answer: 1, 2, 3, 4 Question 47 The triage nurse is tagging victims of a train derailment. One patient has a sucking chest wound, BP 90/50, respirations 32, and is alert and able to respond to questions. Utilizing the identified chart, which colored tag should the nurse assign to the patient?
6. red, immediate threat to life
7. yellow, requiring medical attention but no threat of loss of life
8. green, ambulatory with minor injuries
9. black, not expected to survive Correct Answer: 1 Question 48 A local hospital has coordinated with the county emergency management team to plan and conduct disaster drills on a monthly basis. In which phase of disaster management planning is this hospital functioning?
10. Preparedness
11. Mitigation
12. Response
13. Evaluation Correct Answer: 1 Question 49 A train made up of railroad cars filled with toxic chemicals and a full school bus with 90 children on board collide in a populated area. A huge explosion occurs and a fire develops in a nearby factory. Which approach to care should be used to care for these victims?
14. emergency; use conventional triage
15. emergency; evacuate all ambulatory patients first
16. disaster; employ reverse triage
17. disaster; evacuate critically injured patients first Correct Answer: 3 Question 50 A patient exposed to smallpox would present with a vesicular/pustular rash over which areas of the body? Place an “X” over the areas where the rash would initially present.