EMERGENCY NURSING RATIO : EXAM NO.

1. The following 4 clients are brought to the emergency department triage nurse. The client with
which of these signs should be a priority to be seen for immediate care?
a. A 2-year-old has sclera visible above the iris (sunset eyes)
b. A 3-year-old has a single transverse crease across the entire palm of the hand
c. A 6-month-old breastfed client had 8 wet diapers in the last 24 hours
d. A 9-month-old client’s toes fan out and the big toe dorsiflexes when the foot sole is
stroked
Ans: A
The presence of sunset eyes (sclera above iris) is late sign of increased ICP and a priority. Simian
crease (option 2) is expected findings in down syndrome. The normal diaper count for a 6 month
(option 3) is 6-10 diapers/day. Infants have positive Babinski reflex (option 4) until age 1
˜
This is a sign of 6th cranial nerve palsy (paralysis of upward gaze) as a result of increased ICP/
hydrocephalus. This is an acute, delayed sign and requires timely priority diagnosis and
treatment. This sign is more likely to be noted after the fontanels have closed (posterior by 6
months and anterior by 18 months) and the pressure increases.

2. The client screams at the triage nurse, “You are all incompetent here! I have been waiting for 2
hours!” how should the nurse respond initially?
a. “I know you are upset, but I will have to call security if you continue to scream.”
b. “I see that you are upset. Let’s focus on how I can help you.”
c. “I want you to know that the health care providers (HCPs) are well qualifies
professionals.”
d. “It is frustrating to wait so long, and I am sorry for the delay.”

Ans: D
Therapeutic communication is used to establish trust, encourage communication and display
respect for the client.
Emphasize with the client’s feeling will conveys concerns and understanding on the part of the
nurse and helps establish a therapeutic dialogue.
Offer a blameless apology, where the nurse apologizes for the problem (long wait) without taking
any personal responsibility for causing it.
This technique can be helpful for diffusing negative emotions as client feels acknowledged for the
“wrong” they believe they have endured.
** do not initially ignore the client or use threats, authoritative rules or aggressive behaviors**
3. There has been a major disaster with the collapse of a large building. Hundreds of victims are
expected. The emergency department nurse is sent to triage victims. Which client should the
nurse tag “red” and send to the hospital first?
a. A client at 8 weeks’ gestation with spotting; pulse of 90 bpm
b. A client with bone piercing skin on leg with oozing laceration; pulse of 88 bpm
c. A client with fixed and dilated pupils and no spontaneous respirations
d. A client with see saw chest movement with respirations
Ans: D
EMERGENCY NURSING RATIO : EXAM NO. 1

Triage in a mass casualty incident – AKA – disaster triage – focuses on saving the greatest number
of people with the limited number of resources available.
The 2 most common taught methodologies to assess the trauma in disaster are:
 START – Simple Triaging and Rapid Transport
 SALT – Sort, Assess, Lifesaving interventions and Treatment and transport

** Both systems rapidly assess the following to categorize trauma cases in a minute:
 Circulation
 Respirations
 Mental status

The principle of disaster triage rank trauma in the likelihood of survival if given treatment, not
necessarily the severity of the injury. Clients with significant alteration in ABC ae likely to survive
with timely interventions are given the first priority.
Trauma status is then ranked using the following:
1. RED:
i. highest priority
ii. indicate life threatening injury that a client will survive if treated in the next hour
iii. significant impairment to airway, breathing and circulation
2. YELLOW
a. Could likely wait for 1-2 hours without loss of life and limb
3. GREEN
a. Considered walking wounded and clients may wait hours for treatment
4. BLACK
a. Indicts that the victim is unlikely to survive transport to definitive clinical care due to either the
severity of trauma, insufficient transportation resources, level of available care.

***flail chest- where multiple rib sustains multiple fractures and become independent of
the chest wall, floating on top of the lung and pleura.
The fractured segment moves paradoxically in relationship to the intact chest wall, pushing
outward with expiration and inward during inspiration.

4 Which guiding principle is suitable for dealing with a disaster scenario involving radiation
contamination?
b. Assess for copious secretions to determine exposure
c. Assist the victims farthest from the source first
d. Assists the victims with the most severe symptoms first
e. Monitor for diplopia to determine extent of exposure

Ans: c
The key aspect related to radiation exposure are time and distance.
The greater the distance, the less the dosage received.

Acute radiation syndrome has the following phases:

 EMERGENCY NURSING RATIO : EXAM NO. 1

 Prodromal
 Latent
 Manifest
 Recovery or death

 **initially, all victims will appear well is mainly internal, leads to cell destruction and manifest
later on.
 Victims farthest away from the radiation source are most salvageable. In this scenario, the
principle of disaster nursing is to do the best for the most people with available resources.
 In triaging victims from a radiation contamination disaster, nurses should assist clients who are
farthest away from the source and have the least symptoms.
 (Option 1) nerve agents used as biological weapons (ex. Sarin) inhibit acetyl cholinesterase, and
their effects are caused by the resulting excess acetylcholine.

5. There has been major community disaster. Stable clients need to be discharged to make more beds
available for the victims. Which clients could be discharged safely? Select all that apply.
a. Diagnosed with endocarditis on antibiotics with peripherally inserted central catheter (PICC line)
b. History of multiple sclerosis with ataxia and diplopia
c. One day post-operative from hemicolectomy
d. Reporting abdominal pain with coffee ground emesis
e. Taking warfarin with prothrombin time/International Normalized Ratio of 2x control value

Ans: A,B,E

Ataxia and diplopia are expected s/s of MS. Two times the control value demonstrate that warfarin has
reached a therapeutic level.
The longer the antibiotic course (and follow up lab work) can continue at home through the PICC line.

Note: large intestine peristalsis does not return for up to 3-5 days. The client cannot be discharge until
able to tolerate oral intake with normal elimination. The client has to at least be passing flatus

**coffee ground emesis indicates upper GI bleeding. The etiology and treatment need to be determined
before the client is discharge.

6. Which pediatric respiratory presentation in the emergency department is a priority nursing care?
a. Client with an acute asthma exacerbation but no wheezing
b. Client with bronchiolitis with low grade fever and wheezing
c. Client with runny nose with seal-like barking cough
d. Cystic fibrosis with fever and yellow sputum

Ans: A
When an acute asthma exacerbation occurs, the child has rapid, labored respirations using accessory
muscles. The child often appears tired due to the ongoing effort. In the case of severe construction (from
 EMERGENCY NURSING RATIO : EXAM NO. 1

airway narrowing as a result of bronchial constriction, airway swelling and copious mucus),
wheezing/breath sounds are not heard due to lack of airflow.
This silent chest is an ominous sign and emergency priority. In this situation, the onset of the wheezing will
be an improvement as it shows that air is now moving in the lungs.

Option 2- bronchiolitis is associated with the respiratory syncytial virus. Cell debris clumps and clogs the
airway. Air can get in but has difficulty getting out. Treatment is supportive
Option 3- croup/ laryngotracheobroncholitis- is a viral inflammation and edema of the epiglottis an larynx.
Symptoms include runny nose, tachypnea, inspiratory stridor, and seal like barking cough

Option 4- cystic fibrosis – infection; no signs of respiratory distress.

Option 3- life before limb

7. The nurse receives a report from the paramedic on 4 trauma victims. Which client would need to be
treated first? A client with:
a. Lower rib fractures and stable chest wall
b. Bruising on the anterior chest wall and possible pulmonary contusion
c. Gunshot wound with open pneumonia unstabilized
d. Dyspnea stabilized with intubation and annual resuscitator

Ans: c
A client with an open pneumothorax is in distress and should be seen by the nurse first. The keyword in this
is “unstable”. The clients A,B,D are stable

8. A school nurse observes a 3-year-old begin to choke and turn blue while eating lunch. What should be
the nurse’s initial action?
a. Abdominal thrust
b. Back blows and chest thrusts
c. Blind sweep of the child’s mouth
d. Call 911 for an ambulance

Ans:A
Foreign body aspiration is an emergency that requires immediate intervention when witnessed or
highly suspected. The primary rescue intervention for adults and children over age 1 is abdominal
thrusts, known as the Heimlich maneuver. This maneuver entails applying upward thrusts with a
fist to the upper abdomen just beneath the rib cage. The child is unable to cough or make sounds,
the nurse should ask the child to forcefully cough before intervening. These signs indicate a
partial obstruction still allowing airflow, which may be cleared with string coughing. However,
any signs of respiratory distress (ex. Stridor, inability to speak, weak cough and cyanosis) require
immediate interventions

9. The nurse manager is discussing the facility protocol in the event of tornado with the staff. Which
instruction should the nurse manager include in the discussion? Select all that apply.
a. Open doors to the client rooms.
b. Move beds away from windows
 EMERGENCY NURSING RATIO : EXAM NO. 1

c. Close window shades and curtains

d. Place blanket over clients who are confined to bed
e. Relocate ambulatory clients from the hallways back into their rooms.

Ans: B,C,D
In this weather event, the appropriate nursing actions focus on protecting clients from flying
debris, or glass. The nurse should close doors to each client’s room and move beds away from
the window and close window shades and curtains to protect clients, visitors and staff from
shattering glass and flying debris. Blankets should be placed over clients confined to bed.
Ambulatory clients should be moved into the hallways from their rooms, away from windows.

10. The nurse is assigned to care for four clients. In planning client rounds which client should the nurse
asses first?
a. A post-operative client preparing for discharge with a new medication
b. A client requiring daily dressing changes of recent surgical incision
c. A client scheduled for a chest x-ray after insertion of nasogastric tube
d. A client with asthma who requested a breathing treatment during previous shift.

Ans: D
Airway is always the highest priority, the nurse. Would attend to the client with asthma who
requested a breathing treatment during the previous shift. This could indicate that the client
was experiencing difficulty breathing. The client describes in options 1,2 and 3 have needs that
would be identified as intermediate priorities.

11. The nurse employed in an emergency department is assigned to triage clients coming to the
emergency department for treatment on the evening shift. The nurse should assign priority to which
client?
a. A client complaining muscle aches, a headache and history of seizure
b. A client who twisted her ankle when rollerblading and is requesting medication for pain
c. A client with a minor laceration on the index finger sustained while cutting an eggplant
d. A client with chest pain who states that he just ate pizza that was made with very spicy sauce.

Ans: D

In an emergency department, triage involves brief client assessment to classify according to

their need for care and includes establishing priorities of care. The type of illness or injury, the
severity of the problems, and the resources available govern the process. Clients with trauma,
chest pain, severe respiratory distress or cardiac arrest, limb amputation, and acute
neurological deficits and those who have sustained chemical splashes to the eyes are emergent
and high priority.
Clients with conditions such as simple fracture, asthma without respiratory distress, fever,
hypertension, abdominal pain or renal stones have urgent needs, or second priority. Clients with
conditions such as minor laceration, sprain, cold symptoms are non-urgent or third priority.
EMERGENCY NURSING RATIO : EXAM NO. 1

12. An experienced traveling nurse has been assigned to work in the emergency department; however,
this is the nurse’s first week on the job. Which area of the ED is the most appropriate assignment
for this nurse?
a. Trauma team
b. Triage
c. Ambulatory or fast track clinic
d. Pediatric medicine team

Ans: C
The fast-track clinic deals with clients in relatively stable condition. The triage, trauma and pediatric
medicine areas should be staffed with experienced nurses who know the hospital routines and polices
and can rapidly locate equipment.

13. The nurse is caring for a client with multiple injuries sustained during a head car collision. Which
assessment finding takes priority?
a. A deviated trachea
b. Unequal pupils
c. Ecchymosis in the flank area
d. Irregular apical pulse

Ans: a
A deviated trachea is a symptom of tension pneumothorax, which will result in respiratory
arrest if not corrected. All of the other symptoms are potentially serious but are of lower
priority.

14. A client involved in a one-car rollover comes in with multiple injuries. Lost in order of priority the
interventions that must be initiated for this client.
a. Secure two large bore IV lines and infuse Ringer lactate or normal saline
b. Use the chin lift or jaw thrust maneuver to open the airway
c. Assess for spontaneous respirations
d. Give supplemental oxygen via mask
e. Obtain full set of vital sign measurements
f. Remove or cut away the clients clothing

Ans: C,B,D,A,E,F
For trauma client with multiple injuries, many interventions may occur simultaneously as team
members assist in the resuscitation. A quick assessment of respiratory status precedes intervention.
Opening the airway must precede the administration of oxygen because, if airway is closed, the oxygen
cannot enter the air passages. Starting IV lines for fluid resuscitation is part of supporting circulation.
Remember your ABCD or your primary and secondary assessment and interventions

15. A group of people arrive at the emergency department by private care. They have extreme
periorbital swelling, coughing and tightness in the throat. There is a strong odor emanating from
their clothes. They report exposure to a “gas bomb” that was set off in their house. What is the
priority action?
EMERGENCY NURSING RATIO : EXAM NO. 1

a. Measure vital signs and listen to lung sound

b. Direct clients to the decontamination area
c. Alert security for possible terrorism activity
d. Direct client to cold or clean zones for immediate treatment

Ans: B
Decontaminations in a specified area are a priority. Preforming assessment delays
contamination and does not protect the total environment. Personnel should don PPE before
assisting with decontamination or assessing clients. The clients must undergo decontamination
before entering cold or clean areas. The nurse should notify the charge nurse or nurse manager
about communicating with security regarding potential terrorist activities.

16. The nurse is talking to a group of people about an industrial explosion in which many people were
killed or injured. Which individual has the greatest risk for psychiatric difficulties, such as post-
traumatic stress disorder, related to the incident?
a. Individual who repeatedly watched television coverage of the event
b. Person who recently learned that her son was killed in the incident
c. Individual who witnessed the death of a co-worker during the explosion
d. Person who was injured and trapped for several hours before the rescue

Ans: D
Any of these people may need or benefit from psychiatric counseling. Obviously, there will be
variations in previous coping skills and support system however, a person who experienced a
threat to his/her own life is the greatest risk for psychiatric problems after disaster incidents.

17. Identify the five most critical elements in performing disaster triage for multiple victims.
a. Obtain past medical and surgical history
b. Check airway, breathing and circulation
c. Assess for level of consciousness
d. Visually inspect for gross deformities, bleeding and obvious injuries
e. Note the color, presence of moisture and temperature of the skin
f. Check vital signs, including pulse and respirations

Ans: B,C,D,E,F
Quickly assessing respiratory effort, level of consciousness, obvious injuries, appearance of the
skin (indicative of peripheral perfusion) and vital signs are appropriate for disaster triage. Other
information, such as medical and surgical history, medication history, support system, and last
tetanus booster, would be collected when the staff has more time and resources.

18. An apartment fire spread to seven apartment units. Victims suffer burns, minor injuries, and broken
bones from jumping from windows. Which client should be transported first?
a. A woman who is 5 months pregnant with no apparent injuries
b. A middle-aged man with no injuries who has rapid respirations and cough
c. A 10-year-old man with simple fracture of the humerus who is in severe pain
d. A 20-year-old with first degree burns on her hand and forearms.
EMERGENCY NURSING RATIO : EXAM NO. 1

Ans:B
The man with respiratory distress and coughing should be transported first because he is
probably experiencing smoke inhalation. The pregnant woman is not in imminent danger or
likely to have precipitous delivery. The 10-year-old is not at risk for infection and could be
treated in an outpatient facility. First-degree burns are considered less urgent.

19.A small airplane crashes in a neighborhood of 10 houses. One of the victims appaers to have a
cervical spine injury. What should first aid for this victim include? Select all that apply.
a. Establish an airway with the jaw thrust manuever
b. Immobilize the spine
c. Logroll the victim to the side lying position
d. Elevate the feet 6 inches (15.2 cm)
e. Place a cervical collar around the neck

Ans: A,B
The victim of a neck injury should be immobilized and moved as little as possible. It is also
important to ensure an open airway; this can be accomplished with the jaw thrust maneuver,
which does not require tilting the head. The victim should NOT be rolled to a side-lying position
nor have his feet elevated. Both actions can cause additional injury to the spinal cord. Placing
cervical collar causes movement of the spinal column and should not be done as a first aid
measure

20. The nurse in a the emergency departmet is triaging the following victims of an airplane crash.
Prioritize the client in order in which they should be treated.
a. A 75-year-old with a 2-inch laceration to the left forearm.
b. A 22-year-old with a 2-inch laceration to the left temple, slightly confused.
c. A 14-year-old with a 2-inch laceration to chin, history of asthma, respirations 26 and audible
wheezing
d. A 22-year-old female, 36 weeks pregnant with contractions every 10 to 15 minutes

Ans: C,B,D,A

The 14-year-old asthma needs immediate, lifesaving interventions for the wheezing and should
be seen first. The 22-year-ols who is confused should be seed next to assess for head injury; the
location of the laceration could indicate a significant blunt force traumatic injury. The pregnant
female requires assessment but not urgent unless ither symptoms appear. The 75-year-old is
non urgent and can wait safely for several hours.