U world

1. 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 id 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.”

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**
2. 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

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:
 a. highest priority
b. indicate life threatening injury that a client will survive if treated in the
next hour
c. 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.

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

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:
 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.

4. The nurse is caring for an adult client who was hospitalized after a car accident with third
degree burns over 50% of the body. Which solution can the nurse anticipate using the fluid
resuscitation?
a. 1.45% normal saline
 b. 5% dextrose normal saline
c. 5% dextrose in water
d. Lactated ringers

 Severe burns cause an increase in capillary permeability from the

injured tissue which allows plasma to seep into the surrounding
tissues. This fluid shift cause edema in the tissues and reduces the
circulating blood volume. The fluid loss causes a decrease in organ
perfusion. The best way to get medication into a client’s system is to
access the circulatory system directly.
 Ringer lactate is used during the first 24 hours of burn treatment for
rapid resuscitation as the concentration of electrolytes closely
resembles that of plasma.

Ringer lactate is the fluid of choice in emergency resuscitation of burn clients due to its
close resemblance to the normal plasma.
Both hypotonic (half normal saline or dextrose in water) and hypertonic solutions
SHOULD BE AVOIDED FOR TH FIRST 24 hours.

5. The emergency department nurse is triaging clients. Which neurologic presentation is most
concerning for a serious etiology and should be given priority doe definitive treatment?
a. History of bell’s palsy with unilateral facial droop and drooling
b. History of multiple sclerosis and reporting recent blurred vision
c. Reports unilateral facial pain when consuming hot foods
d. Temple region hit by ball, loss of consciousness, but GCS score is now 14
 Epidural hematoma is an accumulation of blood between the skull bone and dura
mater.
 The majority of epidural hematomas are associated with fracture of the temporal
bone and subsequent rupture or tear of the middle meningeal artery.
 The bleed is arterial in origin and so hematoma develops quickly.
 The clinical presentation of the epidural hematoma is characteristic. The client may
lose consciousness at the time of the impact. The client then regains consciousness
quickly and feels well for some time after the injury.
 This transient period of wellbeing is called lucid interval. It is followed by a quick
decline in mental function that can progress into coma and death.

The classic presentation of intracranial epidural bleed is loss of consciousness to period of lucidity then
the gradual loss of consciousness. The bleed is arterial in origin and so hematoma develops quickly.
Emergent diagnosis and treatment are needed to prevent brain stem herniation.

Option 1 – bell’s palsy – not emergent

Option 2 - MS – chronic, relapsing and remitting degenerative disorder involving the brain; opric neuritis
is common presentation but not life threatening.
Option 3- trigeminal neuralgia – tic douloreux – presents with paroxysm of unilateral excruciating pain
due to CN V ; not life threatening

6. An emergency department nurse is assigned to triage. Which client should the nurse assess
first?
a. Five-year old with superficial leg laceration
b. Lethargic 3-month old with diarrhea for the past 12 hours
c. Seven-year old with elevated temperature of 101F (38.3 C) and hematuria
d. Seventeen-year old with severe, acute abdominal pain

Triaging clients involves decision making about whose needs/problems are most urgent
and create risk of survival.
2 popular frameworks can assist the nurse in making decisions and setting priorities:
 ABC and v/s
 Mental status changes, acute pain, unresolved medical issues, acute elimination
problems, abnormal lab values and risk
 Longer term issues such health education, rest and coping

Infants have high percentage of body water (70-80% of body weight) and dehydrated rapidly.

Infants have high risk of fluid and electrolye disturbances

7. A client is being transferred to another hospital for specialized care in the burn unit. What is the
nurse required to do prior to transport under Emergency Medical Treatment and Active Labor
Act (EMTALA)? Select all that apply.
a. Call a report to the receiving nurse
b. Check if the client’s family was notified of the transfer
c. Confirm that the client’s primary health care provider (HCP) is on staff
d. Notify the client’s insurance company
e. Verify that the receiving facility has available space and staff
Ans: 1,5

EMTALA aka “anti-dumping law” requires that any client presenting for treatment be
appropriately screened for the presence of an emergency medical condition and then stabilized
within the capabilities of the facility. Before transferring a client to another facility, the law
requires:
 Written informed consent from the client
 Documentation that the receiving facility has available space and qualified
personnel
 Assurance that the receiving facility and attending HCP have accepted the client
 Transfer with appropriate personnel, equipment, and mode of transportation
 Inclusions of relevant documents/medical records.
 There musr be HCP to HCP and nurse to nure report called.
Though the client has been accepted, ensuring that the receiving facility has the available space and
staff is essential. Additional staff may have to be called beforehand or bed may not be available yet.

8. 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: 1,2,5

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.

9. 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: 1
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 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.

10. The registered nurse is performing triage at a pediatric emergency department. Which client
should be seen first?
a. Child with history of cystic fibrosis (CF) has new yellow sputum and cough today
b. Crying infant with fiery redness and moist papules in the diaper region
c. Grade school client with swollen ecchymosis ankle after playing basketball
d. Adolescent client with abdominal pain, heart rate 120 bpm and respirations 26 cpm.

Ans: 4

The client with abdominal pain has abnormal vial signs, which is a sign of systemic
conditions. Adult criteria apply to adolescent client in terms of physiological s/s. PR of
120 bpm signals dehydration and this client respirations are above normal. This is the
most serious acuity.

Option 1- history of CF- treat with second; CF clients have chronic respiratory issues
related to the mucus plugging te airways. This client will probably need antibiotics but is
stable and can wait.; no respiratory distress

CF – chronic

Option 2 – infant dermatitis from irritation of urine and tool on the skin. A secondary
infection with candida albicans can occur. Diaper dermatistis is the most common in 9-
12 months. Ointment can be provide. Mild diaper dermatitis is treated wih topical
water-impermeable barrier (ex. Zinc oxide).
If there is infection with candida albicans, an antifungal topical medication is also used.

Prioritization: when care must be prioritized, young children do not automatically go

first. It is decided according to acuity.

Option 3- life before limb

11. 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

12. A mother brings a child to the emergency department with itching and rash shown in the image.
The child continues to scratch the lesions. What action should the
nurse take first?
a. Administer antihistamine and closely crop the fingernails.
b. Ask about the child’s vaccination status
c. Place a mask o the child
d. Place the child in positive airflow room.

Ans: 3

This child has chicken pox (varicella), given the vesicular lesions. Chicken pox is
transmitted primarily by airborne spread of secretions from nasopharyngeal secretions
of an infected individual and trough direct contact of open lesions. It is most contagious
1-2 days before the rash until shortly after onset of rash (until all lesions are crusted
over). Supportive care is usually adequate, and most children recover fully. Children who
are immunocompromised are at risk for complications. Contact and airborne
precautions are used. A mask will help prevent the spread of infections until the child is
placed in isolation negative airflow room.

The priority for a child with chicken pox is isolation – airborne and contact.
Supportive care includes antihististamines for itching and acetaminophen (NOT aspiring)
for fever. Fingernails should be cut short to prevent excoriation and secondary bacterial
infection.

Option 1- antihistamine helps prevent itching ad acetaminophen helps reduce fever.

Fingernails should be but short to prevent excoriation and secondary infection. However
this is not the first priority actions

Option 2 – vaccination history is important but not priority

Option 4 - a positive air pressure pushes air out of the room by increasing the rate of
flow. It is used for immunosuppressed clients to prevent the organisms of a normal
environment from entering the room. A negative pressure air pressure is a ventilation
system that removes more exhaust air from the room than air allowed into the room. It
prevents the infection from spreading out into the environment. A negative air pressure
flow room would be required to prevent the airborne spread of the disease.
13. A client arrives at the emergency department after being rescued from a burnin building. Both
arms and the entire chest are covered with dry,leathery, charred skin that does not blach. What
is the priority for the client’s care?
a. Administration of IVF- lactated ringers
b. Antibiotic administration
 c. Debridement of the burned tissues (escharotomy)
d. IV administration of analgesics

Ans: 1
The initial management of burn injuries is identical to the management of all trauma
clients: ABC
All burn victims should be treated initially with high flow oxygen via a non rebreather
mask, although caregivers should maintain a low threshold for intubation in any client
with physical evidence of thermal damage to the upper airway.

Following severe thermal burns, client require significant volume replacement to

compensate for the fluid lost through their wounds and for potential injury-relatedd
systemic inflammatory response causing increased capillary permieability with
extravascular shift of fluis. Aggressive flui replacement is essential if more than 15%
total body surface TBSA is involved. This client has 36% burn area based on the rule of
nines

Fluid used typically include lactate ringers. The amount of fluid required for the first 24
hours is calculated using the PARKLAND formula (4ml/kg for each percent of TBSA
burned). ½ of the total fluid will be infused in 1 st 8 hours and ½ in 16 hours

Option 2- burn clients are at risk for infection due to lack of skin integrity, especially by
Pseudomonas Aeruginosa, but treatment in the acute setting should focus on
restoration of ABC

Option 3- wound care is important but maintain adequate circulation is priority. This
client has no evidence of circumferential burn requiring eschrotomy. Even if this
procedure is needed, fluid would be the priority as the fluid loss/shift can start as early
as 20 minutes after a burn and fluid resuscitation is life saving.

Option 4- full thickness or 3rd degree burns involve destruction of nerves, so there is o
pain. There may be some other partial thickness or superficial burns that do have severe
pain. Under ABCD prioritization, pain is “D” and would be after circulation for fluids.
14. An adult was severely burned in a warehouse accident. The client has second degree on the
right leg and right arm as well as the back. Using the rule of nines, the nurse estimates the
perentage of the client’s burns as which of thses options?
a. 25%
b. 32%
c. 45%
d. 50%
Ans: c
Using the rule of nines, the nurse would calculate as 45%
Right leg 18%
Right arm 9%
 Back 18%
Total: 45%
The rule of nines is often used at the initial evaluation and should be recalculated within the
first 72 hours.
15. When caring for severe burns, the nurse can expect to administer pain medications via which
route?
a. Intramuscular
b. Intravenous
c. Oral
d. Subcutaneous

Ans: burns cause large fluid shifts and can decrease perfusion to the GIT resulting in
inconsistent absorption of oral medcations. Burns damage the muscle and
subcuataneous tissue causing generalized body edema and decreasing circulationg
blood volume. These physiological changes reduce the absorption ability for the
intramuscular and subcutaneous routes.

Best way to get medications into the system of a client with severe burns is to access
the circulatory system directly via IV route.

In client with severe burns, medications are best administered through the IV route
given the possibility of reduced absorption of reduced absorption from other routes
(SQ,IM and oral)
16. Four clients come to the triage registered nurse in the emergency departmet (ED). According to
triage criteria, which client should be seen first for definitive diagnosis and treatment?
a. A 25 year old client with sudden onsent chest pain rated 5 and heart rate of 110 bpm
who drove to the ED.
b. A 45 year old client with type 2 diabetes who is traveling and has lost insulin glargine
c. A 60 year old client with fever, pain, swelling, erythema, and warmth in the right leg
d. A 70 year old client with left lower abdominal pain who arrives by ambulance.
Ans: 1

The purpose of triage is to sort according to current acuity. All clients will be seen; the
priority is to determine who will be seen first.

All adult clients with chest pain/pressure should be considered cardiac until proven
otherwise and is priority. Most common co-existing morbidities should be used to rule
in, not rule out the possibility. This client could have used cocaine, which causes
coronary artery vasospasm. The standard of care is ECG and enzymes within 10 minutes
of presentation of any adult chest pain. No client should have a cardiac etiology ruled
out on age.

Option 2- prescription renewal – lowest priority

 Option 3- cellulitis (inflammation of SQ tissues) and may require antibiotics (possible
admission for intravenous antibiotics). There is no indication of systemic sepsis. Can
safely wait up to 2 hours for further care.

Option 4- abdominal pain has many etiologies. It is typically classified as severity of 3 on

a 5 level scale. There is no information about such conditions a systemic instability or
peritonitis in this client. Left lower quadrant pain in a client age >50 makes acute
diverticulitis is consideration. Second priority after option 1.
17. The emergency department nurse is assigned to triage. Which of the following clients does the
nurse triage first?
a. A client who smokes with 3 months of intermittent leg cramping pain that get worse
with walking and eases with rest
b. A client with leg swelling and calf pain who flew from Australia to new York 2 days ago
c. A diabetic client with a temperature of 100.7 F (38.2 C)
d. A healthy,afebrile client with edema and redness in the leg following a dog bite 1 hour
ago.
Ans: 2

Emergency department triage requires the nurse to quickly assess client’s needs and
identify which are most urgent to prioritize care. ABC problems take precedence and
have the highest priority and level of risk. Mental status changes, unresolved medical
issues, acute pain and abnormal laboratory values have the second highest priority and
degree of risk; these are followed by longer term issues, which have the lowest level of
risk.

A common risk factor for deep venous thrombosis (DVT) is travelling/ sitting with
prolonged periods (>4hours) of inactivity. Common symptoms of a lower- extremity DVT
include unilateral edema and calf pain. Diagnosis and treatment of DVT (circulation
problem) is high priority because a piece of the clot can break off, travel though the
systemic and/or pulmonary circulation, and cause a life threatening complication (ex.
Pulmonary embolus).

18. 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: 1
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 hve closed (posterior by 6
months and anterior by 18 months) and the pressure increases.
19. 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: 1

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.