. 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 ho...
Exam 1
1. 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
Hand-off communication should be comprehensive so that the receiving nurse can continue care for the client
fluidly. Communication should be concise and should include only the most essential information for a safe
transition in care. Hand-off communication should include the client’s situation (reason for being in the ED), brief
medical history, assessment and diagnostic findings, Transmission-Based Precautions needed,
interventions provided, and response to those interventions.
2. Primary goal of triage by the nurse in the emergency department with Emergency Department patients?
a. Other choice
b. Determine acuity of conditions and establish/prioritize care
c. Other choice
d. Assess ABC’s and deficits
The correct answer is B; D is incorrect because the D in ABCDE stands for disability not deficits
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
The client with pale, cool, clammy skin is in shock and needs immediate medical attention. The mother does
not have injuries and so would be the lowest priority. The other two people need medical attention soon, but
not at the expense of a person in shock.
4. 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
All other members of the health care team listed may be used in the management of this client’s care. However,
the forensic nurse examiner is educated to obtain client histories and collect evidence dealing with the assault
and can offer the counseling and follow-up needed when dealing with the victim of an assault.
5. 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
, The psychiatric crisis nurse evaluates clients with emotional behaviors or mental illness and facilitates follow- up
treatment plans. The psychiatric crisis nurse also works with clients and families when experiencing a crisis.
Paramedics are advanced life support providers who can perform advanced techniques that may include
cardiac monitoring, advanced airway management and intubation, establishing IV access, and administering
drugs en route to the emergency department. The forensic nurse examiner is trained to recognize evidence of
abuse and to intervene on the client’s behalf. The forensic nurse examiner will obtain client histories, collect
evidence, and offer counseling and follow-up care for victims of rape, child abuse, and domestic violence. The
triage nurse performs rapid assessments to ensure clients with the highest acuity receive the quickest
evaluation, treatment, and prioritization of resources. The emergency medical technician is usually the first
caregiver and provides basic life support and transportation to the emergency department.
6. A patient has a 20% burn received 12 hours ago. BP is 90/50, HR 110, urine output is 20mL/hr. Which Rx would
the nurse anticipate?
a. Increase the LR/hr
My guess - to improve fluid resuscitation and increase overall blood volume
b. Administer diuretic to increase urine output
c. Change IV LR to 5% dextrose in water
d. Transfuse RBC
7. Saunders Ch 46 #486: A client is brought to the emergency department with partial-thickness burns to his face,
neck, arms, and chest after trying to put out a car fire. The nurse should implement which nursing actions for this
client? Select all that apply.
1) Restrict fluids
2) assess for airway patency
3) administer oxygen as prescribed
4) place a cooling blanket on the client
5) elevate extremities if no fractures are present
6) administer an EKG
2, 3, & 5. The primary goal for a burn injury is to maintain a patent airway, administer IV fluids to prevent
hypovolemic shock, and preserve vital organ functioning. Therefore, the priority actions are to assess for
airway patency and maintain a patent airway. The nurse then prepares to administer oxygen. Oxygen is
necessary to perfuse vital tissues and organs. An IV line should be obtained, and fluid resuscitation started.
The extremities are elevated to assist in preventing shock and decrease fluid moving to the extremities,
especially in the burn-injured upper extremities. The client is kept warm since the loss of skin integrity
causes heat loss. The client is placed on NPO status because of the altered gastrointestinal function that
occurs as a result of a burn injury.
8. Saunders Ch 46 #489: A client arrives at the Emergency Department following a burn injury that occurred in the
basement at home, and an inhalation injury is suspected. What would the nurse anticipate to be prescribed for
the client?
a. 100% oxygen via an aerosol mask
b. oxygen via nasal cannula at 6 liters per minute
c. oxygen via nasal cannula at 15 liters per minute
d. 100% oxygen via a tight-fitting, nonrebreather face mask
4. If an inhalation injury is suspected, administration of 100% oxygen via a tight-fitting, nonrebreather
facemask is prescribed until carboxyhemoglobin levels fall (usually below 15%). In inhalation injuries,
the oropharynx is inspected for evidence of erythema, blisters, or ulcerations. The need for
endotracheal intubation is also assessed. Administration of oxygen by aerosol mask and cannula are
incorrect and would not provide the necessary oxygen supply needed for adequate tissue perfusion for
the client with a likely inhalation injury. Test taking strategy: focus on the subject, an inhalation injury.
Recalling that 100% oxygen is required following an inhalation injury will assist you in eliminate ING
auctions 2 and 3. From the remaining options, recall that a tight fitting nonrebreather mask is preferred
so that the client will not rebreathe exhaled air.
9. 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
In a disaster, military-style triage is used; this approach identifies the dead or expectant dead with black tags.
This practice helps to maintain the goal of triage, which is doing the most good for the most people. Precious
resources are not used for those with overwhelming critical injury or illness, so that they can be allocated to
others who have a reasonable expectation of survival. Clients are not sacrificed. Telling students to move on
after identifying the expectant dead belittles their feelings and does not provide an adequate explanation.
Clients are not black-tagged to allow volunteers to give comfort care.
10. 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
When deployed, DMAT health care providers are acting as agents of the federal government, and so are
considered federal employees. Thus their licenses are valid in all 50 states. Licensure is an issue that the
government would be concerned with, but no programs for temporary licensure or rapid activation are
available.
11. 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 facility’s sick-leave policy.
c. Arrange for critical incident stress debriefing.
d. Talk individually with staff members.
ANS: C
The staff may be suffering from critical incident stress and needs to have a debriefing by the critical incident
stress management team to prevent the consequences of long-term, unabated stress. Speaking with staff
members individually does not provide the same level of support as a group debriefing. Organizing a party and
revisiting the sick-leave policy may be helpful but are not as important and beneficial as a debriefing.
12. 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
Clients with burns, spine injuries, eye injuries, and stable abdominal injuries should be treated within 30
minutes to 2 hours, and therefore should be identified with yellow tags. The client with the open fractures and
the client with the head injury would be classified as urgent with red tags.
13. 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
To prevent staff post-traumatic stress disorder during a mass casualty event, the nurses should use available
, counseling, encourage and support co-workers, monitor each other’s stress level and performance, take breaks
when needed, talk about feelings with staff and managers, and drink plenty of water and eat healthy snacks for
energy. Nurses should also keep in touch with family, friends, and significant others, and not work for more
than 12 hours per day. Encouraging counseling upon deactivation of the plan, or after the emergency response
is over, does not prevent stress during the casualty event. Assigning staff to unfamiliar roles or units may
increase situational stress and is not an approach to prevent post-traumatic stress disorder.
14. 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
The hospital incident commander assumes overall leadership for implementing the emergency plan. The triage
officer rapidly evaluates each client to determine priorities for treatment. The paramedic provides advanced
life support during transportation to the hospital. The public information officer serves as a liaison between the
health care facility and the media. The medical command physician decides the number, acuity, and resource
needs of clients.
15. 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 you’d like.
ANS: D
Clients should be allowed to ventilate their feelings of anger and despair after a catastrophic event. The nurse
establishes rapport through active listening and honest communication and by recognizing cues that the client
wishes to talk. Asking whether the client is in pain as the first response closes the door to open communication
and limits the client’s options. Simply telling the client to stop yelling and to gain control does nothing to
promote therapeutic communication.
16. 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
Red-tagged clients need immediate care due to life-threatening injuries. A client with severe chest pain would
receive a red tag. Yellow-tagged clients have major injuries that should be treated within 30 minutes to 2
hours. A client with an open fracture with distal pulses would receive a yellow tag. The client with full-thickness
body burns would receive a black tag. The client with a scalp laceration would receive a green tag, and the client
with shortness of breath would receive a red tag.
17. 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. Let’s 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. Let’s pass around the written policy compliance form for everyone.
ANS: A
Strict confidentiality during stress debriefing is essential so that staff members can feel comfortable sharing
their feelings, which should be accepted unconditionally. Brainstorming improvements and discussing policies
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