EMERGENCY ROOM

1. While assessing a client in the emergency department, the nurse identifies that the client
has been raped. Which health care team member should the nurse collaborate with when
planning this client's care?
A. Emergency medicine physician
B. Case manager
C. Forensic nurse examiner
D. Psychiatric crisis nurse

Rationale: 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.

2. On admission to the emergency department, a client states that he feels like killing himself.
When planning this client's care, it is most important for the nurse to coordinate with which
member of the health care team?
A. Case manager
B. Forensic nurse examiner
C. Physician
D. Psychiatric crisis nurse

Rationale: The psychiatric crisis nurse interacts with clients and families in crisis. This health
care team member can offer valuable expertise to the emergency health care team, which also
includes the case manager and the physician.

3. The emergency department team is performing cardiopulmonary resuscitation on a client

when the client's spouse arrives at the emergency department. What should the nurse do
next?
A. Request that the client's 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 client's spouse to the hospital's crisis team.

Rationale: If resuscitation efforts are still under way when the family arrives, one or two family
members may be given the opportunity to be present during lifesaving procedures. The other
options do not give the spouse the opportunity to be present for the client or to begin to have
closure.

4. The emergency department nurse is assigned an older adult client who is confused and
agitated. Which intervention should the nurse include in the client's plan of care?
A. Administer a sedative medication.
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B. Ask a family member to stay with the client.

C. Use restraints to prevent the client from falling.
D. Place the client in a wheelchair at the nurses' station.

Rationale: Older adults who are confused are at increased risks for falls. Fall prevention
includes measures such as side rails up, reorientation, call light in reach, and, in some cases,
asking the family member, significant other, or sitter to stay with the client to prevent falls.

5. An emergency department nurse is transferring a client to the medical-surgical unit. What is

the most important nursing intervention in this situation?
A. Triage the client to determine the urgency of care.
B. Clearly communicate client data to the unit nurse.
C. Evaluate the need for ongoing medical treatment.
D. Perform a thorough assessment of the client.

Rationale: The emergency nurse needs to be able to triage, assess, and evaluate. However,
these steps have already been carried out in the early phases of the emergency department
(ED) admission. When a client is ready to be transferred from the ED, communication with staff
nurses from the inpatient units is essential. This report should be a concise but comprehensive
report of the client's ED experience.

6. The nurse manager is assessing current demographics of the facility's emergency

department (ED) clients. Which population would most likely present to the ED for
treatment of a temperature and a sore throat?
A. Older adults
B. Immunocompromised people
C. Pediatric clients
D. Underinsured people

Rationale: The ED serves as an important safety net for clients who are ill or injured but lack
access to basic health care. Especially vulnerable populations include the underinsured and the
uninsured, who may have nowhere else to go for health care.

7. The emergency department (ED) nurse is caring for the following clients. Which client does
the nurse prioritize to see first?
A. 22-year-old with a painful and swollen right wrist
B. 45-year-old reporting chest pain and diaphoresis
C. 60-year-old reporting difficulty swallowing and nausea
D. 81-year-old with a respiratory rate of 28 breaths/min and a temperature of 101° F
EMERGENCY ROOM

Rationale: A client experiencing chest pain and diaphoresis would be classified as emergent and
would be triaged immediately to a treatment room in the ED. The other clients are more stable.

8. A nurse is triaging clients in the emergency department. Which client complaint would the
triage nurse classify as nonurgent?
A. Chest pain and diaphoresis
B. Decreased breath sounds due to chest trauma
C. Left arm fracture with palpable radial pulses
D. Sore throat and a temperature of 104° F

Rationale: A client in a nonurgent category can tolerate waiting several hours for health care
services without a significant risk of clinical deterioration. The client with chest pain and
diaphoresis and the client with chest trauma are emergent owing to the potential for clinical
deterioration and would be seen immediately. The client with a high fever may be stable now
but also has a risk of deterioration. The client with an arm fracture and palpable radial pulses is
currently stable, is not at significant risk of clinical deterioration, and would be considered
nonurgent.

9. A client has been injured in a stabbing incident. Assessment reveals the following: Blood
pressure: 80/60 mm Hg, Heart rate: 140 beats/min, Respiratory rate: 35 breaths/min,
bleeding from stabbing wound site and client is lethargic. Based on these assessment data,
to which trauma center should the nurse ensure transport of the client?
A. Level I
B. Level II
C. Level III
D. Level IV

Rationale: The Level I trauma center is able to provide a full continuum of care for all client
areas. Level II can provide care to most injured clients, but given the extent of his injuries, a
Level I center would be better if it is available. Both Levels III and IV can stabilize major injuries,
but transport to a higher-level center is preferred, when possible.

10. The emergency medical technicians (EMTs) arrive at the emergency department with an
unresponsive client with an oxygen mask in place. What will the nurse do 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 best neurologic response
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Rationale: The highest-priority intervention in the primary survey is to establish that the client
is breathing adequately. Even though this client has an oxygen mask on, he may not be
breathing, or he may be breathing inadequately with the device in place.

11. A client arrives at the emergency department following a motor vehicle collision. The client
is not awake and is being bagged with a bag-valve-mask by paramedics. The client has
sustained obvious injuries to the head and face, as well as an open right femur fracture that
is bleeding profusely. What will the nurse do first?
A. Splint the right lower extremity.
B. Apply direct pressure to the leg.
C. Assess for a patent airway.
D. Start two large-bore IVs.

Rationale: The highest-priority intervention in the primary survey is to establish a patent

airway. Without an adequate airway to supply oxygen to the cells, a cerebral injury could
progress to anoxic brain death. After an airway is established, resuscitation may continue to B
for breathing and C for circulation assessment.

12. The elderly client is brought to the ED complaining of cramps, headache, and weakness
after working outside in the sun. The telemetry shows sinus tachycardia. Which intervention
should the nurse implement?
A. Determine if the client is experiencing any thirst.
B. Administer D5W intravenously at 250 mL/hr.
C. Maintain a cool environment to promote rest.
D. Withhold the client's oral intake.

Rationale: The nurse should encourage the client to rest and should maintain a cool
environment to assist the client to recover from heat exhaustion. The elderly are more
susceptible to this condition.

13. A trauma client with multiple open wounds is brought to the emergency department in
cardiac arrest. What should the nurse do before 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.

Rationale: Nurses must recognize and plan for a high risk of contamination with blood and body
fluids when engaging in trauma resuscitation. Standard Precautions should be taken in all
resuscitation situations and at other times when exposure to blood and body fluids is likely.
EMERGENCY ROOM

Proper attire consists of an impervious cover gown, gloves, eye protection, a facemask, a
surgical cap, and shoe covers.

14. The nurse is triaging clients in the emergency department. Which client should be
considered urgent?
A. 20-year-old female with a chest stab wound and tachycardia
B. 45 year-old homeless man with a skin rash and sore throat
C. 75-year-old female with a cough and of temperature of 102° F
D. 50-year-old male with new-onset confusion and slurred speech

Rationale: A client with a cough and a temperature of 102° F is urgent. This client is at risk for
deterioration and needs to be seen quickly, but is not in an immediately life-threatening
situation. Clients with a chest stab wound and tachycardia, and with new-onset confusion and
slurred speech, should be triaged as emergent. The client with a skin rash and a sore throat is
not at risk for deterioration and would be triaged as nonurgent.

15. A client in the emergency department has died from a suspected homicide. What is the
nurse's priority intervention?
A. Remove all tubes and wires in preparation for the medical examiner.
B. Limit the number of visitors to minimize the family's trauma.
C. Consult the bereavement committee to follow up with the grieving family.
D. Communicate the client's death to the family in a simple and concrete manner.

Rationale: When dealing with clients and families in crisis, communicate in a simple and
concrete manner to minimize confusion. Tubes must remain in place for the medical examiner.
Family should be allowed to view the body. Offering to call for additional family support during
the crisis is suggested. The bereavement committee should be consulted, but this is not the
priority at this time.

16. A new nurse is orienting to the emergency department (ED). Which statement made by the
nurse would indicate the need for further education by the preceptor?
A. "The emergency medicine physician coordinates care with all levels of the emergency
health care team."
B. "Emergency departments have specialized teams that deal with high-risk populations of
patients."
C. "Many older adults seek emergency services when they are ill because they do not want
to bother their primary health care provider."
D. "Emergency departments are responsible for public health surveillance and emergency
disaster preparedness."
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Rationale: The emergency nurse is one member of the large interdisciplinary team that
provides care for clients in the ED. A collaborative team approach to emergency care is
considered a standard of practice. In this setting, the nurse coordinates care with all levels of
health care team providers, from prehospital emergency medical services (EMS) personnel to
physicians, hospital technicians, and professional and ancillary staff.

17. An unresponsive client with poor ventilator effort and a pulse rate of 120 beats/min arrives
at the emergency department. What should the nurse do first?
A. Place the client on a non-rebreather mask.
B. Begin bag-valve-mask ventilation.
C. Initiate cardiopulmonary resuscitation.
D. Prepare for chest tube insertion.

Rationale: Apneic clients and those with poor ventilatory effort need bag-valve-mask (BVM)
ventilation for support until endotracheal intubation is performed and a mechanical ventilator
is used. A non-rebreather mask would be appropriate only if the client had adequate
spontaneous ventilation. Cardiopulmonary resuscitation is necessary only if the client is
pulseless. Chest tubes are inserted for decompression and pneumothorax.

18. The nurse is triaging clients in the emergency department (ED). Which is true about the
presentation of client symptoms?
A. Older adults frequently have symptoms that are vague or less specific.
B. Young adults present with nonspecific symptoms for serious illnesses.
C. Diagnosing children's symptoms often keeps them in the ED longer.
D. Symptoms of confusion always represent neurologic disorders.

Rationale: Older adults present with symptoms that often are different or less specific than
those of younger adults. For example, increasing weakness, fatigue, and confusion may be the
only admission concerns. These vague symptoms can be caused by serious illness, such as an
acute myocardial infarction (MI), urinary tract infection, or pneumonia. Diagnosing older adults
often keeps them in the ED for extended periods of time.

19. The emergency department (ED) nurse is assigned to triage clients. What is the purpose of
triage?
A. Treat clients on a first-come, first-serve basis.
B. Identify and treat clients with low acuity first.
C. Prioritize clients based on illness severity.
D. Determine health needs from a complete assessment.

Rationale: ED triage is an organized system for sorting or classifying clients into priority levels,
depending on illness or injury severity. The key concept is that clients who present to the ED
EMERGENCY ROOM

with the greatest acuity needs receive the quickest evaluation, treatment, and prioritized
resource utilization. A person with a lower-acuity problem may wait longer in the ED because
the higher-acuity client is moved to the "head of the line."

20. The nurse is caring for a homeless client and consults the emergency department (ED) case
manager. What can the ED case manager do for this client?
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.

Rationale: Case management interventions include facilitating referrals to primary care

providers who are accepting new clients or to subsidized community-based health clinics for
clients or families in need of routine services. The ED nurse is accountable for communicating
pertinent staff considerations, client needs, and restrictions to support staff (e.g., physical
limitations, isolation precautions) to ensure that ongoing client and staff safety issues are
addressed. The ED physician prescribes medications and treatments. The psychiatric nurse
team evaluates clients with emotional behaviors or mental illness and facilitates the follow-up
treatment plan, including possible admission to an appropriate psychiatric facility.

21. The emergency department (ED) nurse is preparing to transfer a client to the critical care
unit. What information should the nurse include in the nurse-to-nurse hand-off report?
(Select all that apply.)
A. Allergies
B. Vital signs
C. Immunizations
D. Marital status
E. Isolation precautions

Rationale: Hand-off communication should be comprehensive so that the 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.

22. The nurse is discharging an older adult client home from the emergency department (ED)
after an acute episode of angina. What should the nurse do to ensure client safety upon
discharge? (Select all that apply.)
A. Reconcile the client's prescription and over-the-counter medications
B. Screen the client for functional and cognitive abilities, as well as risk for falls
EMERGENCY ROOM

C. Consult physical therapy to organize for home health services

D. Arrange for the client's car keys to be taken to prevent an accident
E. Review discharge instructions with the client and a family member

Rationale: Before discharge, the nurse should ensure that the client's prescription and over-
the-counter medications are evaluated to determine whether the drug regimen should be
continued. Discharge education should be provided to the client and a significant other or
family member. To prevent future ED visits, screen older adults per agency policy for functional
assessment, cognitive assessment, and risk for falls. Case management should be consulted to
organize home health services. The nurse should emphasize safety when driving but cannot
organize to take the client's keys away.

23. The ED nurse is caring for a client diagnosed with frostbite of the feet. Which intervention
should the nurse implement?
A. Massage the feet vigorously.
B. Soak the feet in warm water.
C. Apply a heating pad to feet.
D. Apply petroleum jelly to feet.

Rationale: Heating pads are not used to rewarm tissue with frostbite. Heating pads can cause
tissue damage from burns, especially in tissue with impaired sensation.

24. The ED nurse is caring for a male client admitted with carbon monoxide poisoning. Which
intervention requires the nurse to notify the Rapid Response Team?
A. The client has expectorated black sputum.
B. The client reports trying to kill himself.
C. The client's pulse oximeter reading is 94%.
D. The client has stridor and reports dizziness.

Rationale: Stridor or dizziness indicates an occlusion of the airway, which is a medical

emergency. The RRT is called when the client is experiencing a decline but is still breathing.

25. In what sequence would a client move through the process of admission to disposition in
emergency care? (Place in order of priority.)
A. Client is transported to the medical-surgical floor. (6)
B. Emergency department (ED) nurse gives a report on the client. (5)
C. Paramedics arrive and start IV access. (2)
D. Nurse and other health care provider(s) perform assessment. (3)
E. Emergency medical technicians (EMTs) provide oxygen and vital sign monitoring. (1)
F. Laboratory technician obtains blood specimens. (4)
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Rationale: When clients are in an emergency situation, EMTs arrive on the scene first. EMTs
apply oxygen and obtain vital signs to determine a baseline for further care. EMTs can provide
basic life support measures and can assess ABCs. Second on the scene are paramedics. Starting
IV access and performing advanced life support is within the paramedic's scope of practice. The
client is then transported to an ED, where nurses and other health care providers perform an
initial assessment. Laboratory technicians are notified and appropriate blood specimens are
obtained for diagnostic testing. When the client is stable, the ED nurse gives report to the
medical-surgical unit nurse, and the client is finally transferred to an inpatient room.

26. An emergency room nurse assesses a client who has been raped. With which health care
team member should the nurse collaborate when planning this client's care?
A. Emergency medicine physician
B. Case manager
C. Forensic nurse examiner
D. Psychiatric crisis nurse

Rationale: 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.

27. The emergency department team is performing cardiopulmonary resuscitation on a client

when the client's spouse arrives at the emergency department. Which action should the
nurse take first?
A. Request that the client's 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 client's spouse to the hospitals crisis team.

Rationale: If resuscitation efforts are still under way when the family arrives, one or two family
members may be given the opportunity to be present during lifesaving procedures. The other
options do not give the spouse the opportunity to be present for the client or to begin to have
closure.

28. 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
EMERGENCY ROOM

Rationale: 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.

29. 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.

Rationale: A client with signs and symptoms of tuberculosis or other airborne pathogens should
be placed in a negative-pressure room to prevent contamination of staff, clients & family
members in the crowded emergency department.

30. 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

Rationale: A client experiencing chest pain and diaphoresis would be classified as emergent and
would be triaged immediately to a treatment room in the ED. The other clients are more stable.

31. 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

Rationale: Level I trauma centers are usually located in large teaching hospital systems and
provide a full continuum of trauma care for all clients. Both Level II and Level III facilities are
usually located in community hospitals. These trauma centers provide care for most clients and
transport to Level I centers when client needs exceed resource capabilities. Level IV trauma
centers are usually located in rural and remote areas. These centers provide basic care,
stabilization, and advanced life support while transfer arrangements to higher-level trauma
centers are made.
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32. 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.

Rationale: The highest-priority intervention in the primary survey is to establish that the client
is breathing adequately. Even though this client has an oxygen mask on, he or she may not be
breathing, or may be breathing inadequately with the device in place.

33. 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.

Rationale: Nurses must recognize and plan for a high risk of contamination with blood and body
fluids when engaging in trauma resuscitation. Standard Precautions should be taken in all
resuscitation situations and at other times when exposure to blood and body fluids is likely.
Proper attire consists of an impervious cover gown, gloves, eye protection, a facemask, a
surgical cap, and shoe covers.

34. 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

Rationale: A client with a cough and a temperature of 102 F is urgent. This client is at risk for
deterioration and needs to be seen quickly, but is not in an immediately life-threatening
situation. The client with a chest stab wound and tachycardia and the client with new-onset
confusion and slurred speech should be triaged as emergent. The client with a skin rash and a
sore throat is not at risk for deterioration and would be triaged as nonurgent.

35. An emergency department nurse is caring for a client who has died from a suspected
homicide. Which action should the nurse take?
EMERGENCY ROOM

A. Remove all tubes and wires in preparation for the medical examiner.
B. Limit the number of visitors to minimize the family's trauma.
C. Consult the bereavement committee to follow up with the grieving family.
D. Communicate the client's death to the family in a simple and concrete manner.

Rationale: When dealing with client's and families in crisis, communicate in a simple and
concrete manner to minimize confusion. Tubes must remain in place for the medical examiner.
Family should be allowed to view the body. Offering to call for additional family support during
the crisis is suggested. The bereavement committee should be consulted, but this is not the
priority at this time.

36. 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.

Rationale: Case management interventions include facilitating referrals to primary care

providers who are accepting new clients or to subsidized community-based health clinics for
clients or families in need of routine services. The ED nurse is accountable for communicating
pertinent staff considerations, client needs, and restrictions to support staff to ensure that
ongoing client and staff safety issues are addressed. The ED physician prescribes medications
and treatments. The psychiatric nurse team evaluates clients with emotional behaviors or
mental illness and facilitates the follow-up treatment plan, including possible admission to an
appropriate psychiatric facility.

37. 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 client's concerns and needs.
D. Ask security to store the client's belongings.

Rationale: To demonstrate behaviors that promote trust with homeless clients, the emergency
room nurse should make eye contact (if culturally appropriate), speak calmly, avoid any
prejudicial or stereotypical remarks, show genuine care and concern by listening, and follow
through on promises. The nurse should also respect the client's belongings and personal space.

38. A nurse is triaging clients in the emergency department. Which client should the nurse
classify as nonurgent?
EMERGENCY ROOM

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

Rationale: A client in a nonurgent category can tolerate waiting several hours for health care
services without a significant risk of clinical deterioration. The client with a simple arm fracture
and palpable radial pulses is currently stable, is not at significant risk of clinical deterioration,
and would be considered nonurgent. The client with chest pain and diaphoresis and the client
with chest trauma are emergent owing to the potential for clinical deterioration and would be
seen immediately. The client with a high fever may be stable now but also has a risk of
deterioration.

39. A nurse is caring for clients in a busy emergency department. Which actions should the
nurse take to ensure client and staff safety? (SATA)
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.

Rationale: To ensure client and staff safety, nurses should use two identifiers per The Joint
Commissions National Patient Safety Goals; follow the hospitals security plan, including de-
escalation strategies for people who demonstrate aggressive or violent tendencies; and search
belongings to identify essential medical information. Nurses should also use standard fall
prevention interventions, including leaving stretchers in the lowest position with rails up, and
isolating clients who present with signs and symptoms of contagious infectious disorders.

40. 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? (SATA)
A. Mechanism of injury
B. Diagnostic test results
C. Immunizations
D. List of home medications
E. Isolation precautions
EMERGENCY ROOM

Rationale: 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 clients 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.

41. An emergency room nurse is caring for a trauma client. Which interventions should the
nurse perform during the primary survey? (SATA)
A. Foley catheterization
B. Needle decompression
C. Initiating IV fluids
D. Splinting open fractures
E. Endotracheal intubation
F. Removing wet clothing
G. Laceration repair

Rationale: The primary survey for a trauma client organizes the approach to the client so that
life-threatening injuries are rapidly identified and managed. The primary survey is based on the
standard mnemonic ABC, with an added D and E: Airway and cervical spine control; Breathing;
Circulation; Disability; and Exposure. After the completion of primary diagnostic and laboratory
studies, and the insertion of gastric and urinary tubes, the secondary survey (a complete head-
to-toe assessment) can be carried out.

42. The complex care provided during an emergency requires interdisciplinary collaboration.
Which interdisciplinary team members are paired with the correct responsibilities? (SATA)
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

Rationale: 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
EMERGENCY ROOM

management and intubation, establishing IV access, and administering drugs en route to the
emergency department.

43. 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? (SATA)
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.

Rationale: Due to the high rate of suicide among older adults, a nurse should assess all older
adults for depression and suicide. The nurse should also screen older adults for functional
assessment, cognitive assessment, and risk for falls to prevent future ED visits.

44. Four victims of an automobile crash are brought by ambulance to the emergency
department. The triage nurse determines that the victim who has the highest priority for
treatment is the one with
A. Severe bleeding of facial and head lacerations.
B. An open femur fracture with profuse bleeding.
C. A sucking chest wound.
D. Absence of peripheral pulses.

Rationale: Most immediate deaths from trauma occur because of problems with ventilation, so
the patient with a sucking chest wound should be treated first. Face and head fractures can
obstruct the airway, but the patient with facial injuries has lacerations only. The other two
patients also need rapid intervention but do not have airway or breathing problems.

45. A triage nurse in a busy emergency department assesses a patient who complains of 6/10
abdominal pain and states, "I had a temperature of 104.6º F (40.3º C) at home." The nurse's
first action should be to
A. Tell the patient that it may be several hours before being seen by the doctor.
B. Assess the patient's current vital signs.
C. Obtain a clean-catch urine for urinalysis.
D. Ask the health care provider to order a nonopioid analgesic medication for the patient.

Rationale: The patient's pain and statement about an elevated temperature indicate that the
nurse should obtain vital signs before deciding how rapidly the patient should be seen by the
health care provider. A urinalysis may be needed, but vital signs will provide the nurse with
more useful data for triage. The health care provider will not order a medication before
assessing the patient.
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46. During the primary assessment of a trauma victim, the nurse determines that the patient
has a patent airway. The next assessment by the nurse should be to
A. Check the patient's level of consciousness.
B. Examine the patient for any external bleeding.
C. Observe the patient's respiratory effort.
D. Palpate for the presence of peripheral pulses.

Rationale: Even with a patent airway, patients can have other problems that compromise
ventilation, so the next action is to assess the patient's breathing. The other actions are also
part of the initial survey but are not accomplished as rapidly as the assessment of breathing.

47. During the primary assessment of a patient with multiple trauma, the nurse observes that
the patient's right pedal pulses are absent and the leg is swollen. The nurse's first action
should be to
A. Initiate isotonic fluid infusion through two large-bore IV lines.
B. Send blood to the lab for a complete blood count (CBC).
C. Finish the airway, breathing, circulation, disability survey
D. Assess further for a cause of the decreased circulation.

Rationale: The assessment data indicate that the patient may have arterial trauma and
hemorrhage. When a possibly life-threatening injury is found during the primary survey, the
nurse should immediately start interventions before proceeding with the survey. Although a
CBC is indicated, administration of IV fluids should be started first. Completion of the primary
survey and further assessment should be completed after the IV fluids are initiated.

48. When caring for a patient with head and neck trauma after a motorcycle accident, the
emergency department nurse's first action should be to
A. Suction the mouth and oropharynx.
B. Immobilize the cervical spine.
C. Administer supplemental oxygen.
D. Obtain venous access.

Rationale: When there is a risk of spinal cord injury, the nurse's initial action is immobilization
of the cervical spine during positioning of the head and neck for airway management.
Suctioning, supplemental oxygen administration, and venous access are also necessary after the
cervical spine is protected by immobilization.

49. A patient has been brought to the emergency department with a gunshot wound to the
abdomen. In obtaining a history of the incident to determine possible injuries, the nurse
asks:
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A. "Where did the incident occur?"

B. “What direction did the bullet enter the body?"
C. "How long ago did the incident happen?"
D. "What emergency care was started at the scene?"

Rationale: The entry point and direction of the bullet will help to predict the type of injuries the
patient has. The other information is not as useful in determining which diagnostic studies and
care are needed immediately.

50. A 67-year-old patient who has fallen from a ladder is transported to the emergency
department by ambulance. The patient is unconscious on arrival and accompanied by family
members. During the primary survey of the patient, the nurse should
A. Assess a full set of vital signs.
B. Obtain a Glasgow Coma Scale score.
C. Attach a cardiac ECG monitor.
D. Ask about chronic medical conditions.

Rationale: The Glasgow Coma Scale is included when assessing for disability during the primary
survey. The other information is part of the secondary survey.

51. A 24-year-old is brought to the emergency department with multiple lacerations and tissue
avulsion of the right hand after catching the hand in a produce conveyor belt. When asked
about tetanus immunization, the patient says, "I've never had any vaccinations." The nurse
will anticipate administration of tetanus
A. Immunoglobulin.
B. Immunoglobulin and diphtheria toxoid.
C. Immunoglobulin, tetanus-diphtheria toxoid, and pertussis vaccine.
D. Immunoglobulin and tetanus-diphtheria toxoid.

Rationale: For a patient with unknown immunization status, the tetanus immune globulin is
administered along with the Tdap (since the patient has not had pertussis vaccine previously).
The other immunizations are not sufficient for this patient.

52. A patient has experienced blunt abdominal trauma from a motor vehicle accident. The
nurse should explain to the patient the purpose of
A. Magnetic resonance imaging (MRI).
B. Ultrasonography.
C. Peritoneal lavage.
D. Nasogastric (NG) tube placement.
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Rationale: If intra-abdominal bleeding is suspected, focused abdominal ultrasonography is

obtained to look for intraperitoneal bleeding. MRI would not be used. Peritoneal lavage is an
alternative, but it is more invasive. An NG tube would not be helpful in diagnosis of intra-
abdominal bleeding.

53. A patient is brought to the hospital in cardiac arrest by emergency personnel who are
performing resuscitation. The spouse arrives as the patient is taken into a treatment room
and asks to stay with the patient. The nurse should
A. Have the spouse wait outside the treatment room with a designated staff member to
provide emotional support.
B. Bring the spouse into the room and ensure him or her that a member of the team will
explain the care given and answer questions.
C. Explain that the presence of family members is distracting to staff and might impair the
resuscitation efforts.
D. Advise the spouse that if the resuscitation effort is unsuccessful, the memories may
have an adverse impact on grieving.

Rationale: Family members and patients report benefits from family presence during
resuscitation efforts, so the nurse should try to accommodate the spouse. Having the spouse
wait outside the room is not as supportive to the spouse or patient. It would be inappropriate
to imply that the spouse's presence would have adverse consequences for the patient. Family
members do not report problems with grieving caused by being present during resuscitation
efforts.

54. The triage nurse is working in the emergency department. Which client should be assessed
first?
A. The 10-year-old child whose dad thinks the child's leg is broken.
B. The 45-year-old male who is diaphoretic and clutching his chest.
C. The 58-year-old female complaining of a headache and seeing spots.
D. The 25-year-old male who cut his hand with a hunting knife.

Rationale: The triage nurse should see this client first because these are symptoms of a
myocardial infarction, which is potentially life threatening.

55. The nurse is teaching a class on disaster preparedness. Which are components of an
Emergency Operations Plan (EOP)? Select all that apply.
A. A plan for practice drills.
B. A deactivation response.
C. A plan for internal communication only.
D. A pre-incident response.
E. A security plan.
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Rationale: Practice drills allow for troubleshooting any issues before a real-life incident occurs.
A deactivation response is important so resources are not overused, and the facility can then
get back to daily activities and routine care. A coordinated security plan involving facility and
community agencies is the key to controlling an otherwise chaotic situation.

56. The client has been brought to the ED by ambulance following a motor-vehicle accident
with a flail chest, an intravenous line, and a Heimlich valve. Which intervention should the
nurse implement first
A. Start a large-bore intravenous access.
B. Request a portable chest x-ray.
C. Prepare to insert chest tubes.
D. Assess the cardiac rhythm on the monitor.

Rationale: The client will require a chest tube because the Heimlich valve is only temporary;
therefore, the nurse should prepare for this first.

57. The nurse in a disaster is triaging the following clients. Which client should be triaged as an
Expectant Category, priority 4, and color black?
A. The client with a sucking chest wound who is alert.
B. The client with a head injury who is unresponsive.
C. The client with an abdominal wound and stable vital signs.
D. The client with a sprained ankle which may be fractured.

Rationale: This client has a very poor prognosis, and even with treatment, survival is unlikely.

58. Which federal agency is a resource for the nurse volunteering at the American Red Cross
who is on a committee to prepare the community for any type of disaster?

A. The Joint Commission (JC).

B. Office of Emergency Management (OEM).
C. Department of Health and Human Services (DHHS).
D. Metro Medical Response Systems (MMRS).

Rationale: Federal resources include organizations such as DHHS and the Department of
Justice. Each of these federal departments oversees hundreds of agencies, including the
American Red Cross, which respond to disasters.

59. Which situation requires the emergency department manager to schedule and conduct a
Critical Incident Stress Management (CISM)?
A. Caring for a two (2)-year-old child who died from severe physical abuse.
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B. Performing CPR on a middle-aged male executive who died.

C. Responding to a 22-victim bus accident with no apparent fatalities.
D. Being required to work 16 hours without taking a break.

Rationale: CISM is an approach to preventing and treating the emotional trauma affecting
emergency responders as a consequence of their job. Performing CPR and treating a young
child affects the emergency personnel psychologically, and the death increases the traumatic
experience.

60. During a disaster, a local news reporter comes to the emergency department requesting
information about the victims. Which action is most appropriate for the nurse to
implement?
A. Have security escort the reporter off the premises.
B. Direct the reporter to the disaster command post.
C. Tell the reporter this is a violation of HIPAA.
D. Request the reporter to stay out of the way.

Rationale: Emergency operations plans will have a designated disaster plan coordinator. All
public information should be routed through this person.

61. The triage nurse has placed a disaster tag on the client. Which action warrants immediate
intervention by the nurse?
A. The nurse documents the tag number in the disaster log.
B. The unlicensed assistive personnel documents vital signs on the tag.
C. The health-care provider removes the tag to examine the limb.
D. The LPN securely attaches the tag to the client's foot.

Rationale: The tag should never be removed from the client until the disaster is over or the
client is admitted and the tag becomes a part of the client's record. The HCP needs to be
informed immediately of the action.

62. The father of a child brought to the emergency department is yelling at the staff and
obviously intoxicated. Which approach should the nurse take with the father?
A. Talk to the father in a calm and low voice.
B. Tell the father to wait in the waiting room.
C. Notify the child's mother to come to the ED.
D. Call the police department to come and arrest him.

Rationale: This will help diffuse the escalating situation and attempt to keep the father calm.
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63. A gang war has resulted in 12 young males being brought to the emergency department.
Which action by the nurse is priority when a gang member points a gun at a rival gang
member in the trauma room?
A. Attempt to talk to the person who has the gun.
B. Explain to the person the police are coming.
C. Stand between the client and the man with the gun.
D. Get out of the line of fire and protect self.

Rationale: Self-protection is priority; the nurse is not required to be injured in the line of duty.

64. The nurse is the first responder after a tornado has destroyed many homes in the
community. Which victim should the nurse attend to first?
A. A pregnant woman who exclaims, "My baby is not moving."
B. A child who is complaining, "My leg is bleeding so bad, I am afraid it is going to fall
off!"
C. A young child standing next to an adult family member who is screaming, "I want my
mommy!"
D. An older victim who is sitting next to her husband sobbing, "My husband is dead. My
husband is dead."

Rationale: Priority nursing care in disaster situations needs to be delivered to the living and not
the dead. The child who is bleeding badly is the priority. The bleeding could be from an arterial
vessel; if the bleeding is not stopped, the child is at risk for shock and death. The pregnant
client is the next priority, but the absence of fetal movement may or may not be indicative of
fetal demise. The young child is with a family member and is safe at this time. The older victim
will need comfort measures; there is no information indicating she is physically hurt.

65. The community health nurse is working with disaster relief after a tornado. The nurse
assists in finding safe housing for survivors, providing support to families, organizing
counseling, and securing physical care when needed. Which level of prevention does the
nurse exercise?
A. Primary level of prevention
B. Secondary level of prevention
C. Tertiary level of prevention
D. Quaternary level of prevention

Rationale: Tertiary prevention involves reduction of the amount and degree of disability, injury,
and damage after a crisis. Primary prevention means keeping the crisis from occurring, and
secondary prevention focuses on reducing the intensity and duration of a crisis. There is no
known quaternary prevention level.
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66. The nurse in the hospital emergency department is notified by emergency medical services
that several victims who survived a plane crash will be transported to the hospital. Victims
are suffering from cold exposure because the plane plummeted and was submerged in a
local river. What is the initial action of the nurse?
A. Call the nursing supervisor to activate the agency disaster plan.
B. Supply the triage rooms with bottles of sterile water and normal saline.
C. Call the intensive care unit to request that nurses be sent to the emergency department.
D. Call the laundry department, and ask the department to send as many warm blankets as
possible to the emergency department.

Rationale: In an external disaster, many people may be brought to the emergency department
for treatment. The initial nursing action must be to activate the disaster plan. Although options
B, C, and D may be additional measures that the nurse would take, the initial action would be to
activate the disaster plan.

67. The nurse is reviewing the manual of disaster preparedness and response for the annual
hospital disaster drill. The nurse reads that which are functions of the American Red Cross
(ARC) as opposed to the Federal Emergency Management Agency (FEMA) in the United
States? Select all that apply.
A. Provide monetary relief.
B. Provide crisis counseling.
C. Identify and train personnel.
D. Issue presidential declarations.
E. Deploy National Guard troops.
F. Handle inquiries from families.

Rationale: In general, the ARC provides support to individuals involved in a disaster, whereas
FEMA deals with regional responses to disasters, such as issuing presidential declarations,
providing monetary relief, and deploying National Guard troops. The ARC has been given
authority by the federal government to identify and train personnel for a disaster and provide
disaster relief, including crisis counseling, operating shelters, and handling inquiries from
families.

68. The community health nurse is preparing to teach personnel and family preparedness for
disasters to a group of parents of school-age children. Which items should the nurse plan to
include in disaster preparedness? Select all that apply.
A. Flashlight
B. Supply of batteries
C. Battery-operated radio
D. Extra pair of eyeglasses
E. 4-week supply of water
EMERGENCY ROOM

F. 4-week supply of nonperishable food

Rationale: Options A, B, C, and D should be identified as items to have on hand as part of

disaster preparedness. A 3-day supply of water is recommended (1 gallon per client per day).
Similarly, a 3-day supply of nonperishable food is recommended. A 4-week supply of water and
food is unnecessary and not recommended.

69. The nurse is the first responder at the scene of a 6-car crash on a highway. Which victim
should the nurse attend to first?
A. A victim experiencing dyspnea
B. A victim experiencing confusion
C. A victim experiencing tachycardia
D. A victim experiencing intense pain

Rationale: The client experiencing dyspnea is the priority. Needs related to maintaining a
patent airway are always the priority. The victims experiencing confusion, tachycardia, and
intense pain would be assessed following stabilization of the client with an airway problem.

70. The nurse in charge of a nursing unit is asked to select the hospitalized clients who can be
discharged so that hospital beds can be made available for victims of a community disaster.
Which clients can be safely discharged? Select all that apply.
A. A client with chest pain
B. A client with a Holter monitor
C. A client receiving oral antibiotics
D. A client experiencing sinus rhythm
E. A client newly diagnosed with atrial fibrillation
F. A client experiencing third-degree heart block who requires a pacemaker

Rationale: Clients should be medically stable if discharged and should be able to manage their
condition at home. A client experiencing chest pain could be having a myocardial infarction and
needs frequent monitoring. A client newly diagnosed with atrial fibrillation requires medication
and monitoring to stabilize the condition. A client in third-degree heart block is considered
unstable, especially if the client needs a pacemaker.

71. The nurse in charge of a nursing unit is asked to select those hospitalized clients who can be
discharged so that hospital beds can be made available for victims of a community disaster.
Which clients can be safely discharged? Select all that apply.
A. The client with heart failure (HF) who has bilateral rhonchi
B. The client who 24 hours earlier gave birth to her second child by caesarean delivery
C. The 48-hour postoperative client who has undergone an ileostomy because of
ulcerative colitis
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D. The client with peritonitis caused by a ruptured appendix who is febrile with a
temperature of 102°F (38.9°C)
E. The 2-day postoperative client who has undergone total knee replacement and is
ambulating with a walker
F. The 3-day postoperative client who has undergone coronary artery bypass grafting
and is ready for rehabilitation

Rationale: The client who remains febrile with peritonitis and the client who has continuing
rhonchi with heart failure need to be monitored on an ongoing basis. The remaining clients
could be cared for at home with the help of a home health care nurse.

72. The nurse from a medical unit is called to assist with care for clients coming into the
hospital emergency department during an external disaster. Using principles of triage
during a disaster, the nurse should attend to the client with which problem first?
A. Fractured tibia
B. Penetrating abdominal injury
C. Bright red bleeding from a neck wound
D. Open massive head injury in deep coma

Rationale: The client with arterial bleeding from a neck wound is in immediate need of
treatment to save the client's life. This client is classified as such and would wear a color tag of
red from the triage process. The client with a penetrating abdominal injury would be tagged
yellow and classified as "delayed," requiring intervention within 30 to 60 minutes. A green or
"minimal" designation would be given to the client with a fractured tibia, who requires
intervention but who can provide self-care if needed. A designation of expectant is applied to
the client with massive head or other injuries and minimal chance of survival; the
corresponding color code is black in the triage process. Such clients receive supportive care and
pain management but are given definitive treatment last.

73. The nurse is the first responder at the scene of a train accident. Which victim should the
nurse attend to first?
A. A victim experiencing excruciating pain
B. A victim experiencing moderate anxiety
C. A victim experiencing airway obstruction
D. A victim experiencing altered level of consciousness

Rationale: Client needs related to maintaining a patent airway are always the priority.
Therefore, the nurse would attend to the victim experiencing airway obstruction first. Care to
the other victims follows.
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74. The nurse in charge of a nursing unit is asked to select the hospitalized clients who can be
discharged so that hospital beds can be made available for victims of a community disaster.
Select the clients who can be safely discharged. Select all that apply.
A. A client with dyspnea
B. A client experiencing sinus rhythm
C. A client receiving oral anticoagulants
D. A client with chronic atrial fibrillation
E. A client experiencing third-degree heart block
F. A client who has not voided since before surgery

Rationale: Clients should be medically stable if discharged and should be able to manage their
condition at home independently, with family assistance, or with community services. The
client in option 2 is stable because sinus rhythm is a normal finding. Oral anticoagulants can be
taken at home as long as the client understands how to take the medication and is provided
with education about the medication. The client in option 4 can be discharged because the
client's condition is chronic, not acute. The client experiencing dyspnea is not considered stable.
The client experiencing third-degree heart block is considered unstable and will most likely
need a pacemaker insertion. Clients should not be discharged after surgery until they have
voided.

75. The nurse is the first responder at the scene of a train accident. Which victim should the
nurse attend to first?
A. A middle-aged man with 1 foot trapped under the wreckage
B. A crying teenager who is holding pressure on an arm laceration
C. A young woman who appears dazed and confused and is shivering
D. A screaming middle-aged woman looking frantically for her husband

Rationale: The young woman is demonstrating classic signs of shock, possibly from a closed
head injury. Initial management of a client displaying signs of shock includes management of
airway, breathing, and circulation. Initial treatment includes keeping the client warm.
Oxygenation and intravenous fluids will be needed immediately to stabilize and maintain tissue
perfusion.

76. Which client should the emergency department triage nurse classify as emergent?
A. A client with a displaced fracture who is crying
B. A client with a simple laceration and soft tissue injury
C. A client with crushing substernal pain who is short of breath
D. A client with a temperature of 101°F (38.3°C) with a productive cough
EMERGENCY ROOM

Rationale: The emergent category implies that a condition exists that poses an immediate
threat to life or limb. An example of a client who fits into this category is the client experiencing
crushing substernal pain who is short of breath.

77. A nursing student is studying about disasters and emergency preparedness. Which of the
following statements by the nursing student depicts a correct understanding of the
difference between a disaster and an emergency?
A. "Disasters are manmade only."
B. "An emergency is an unforeseen combination of circumstances calling for immediate
action for a range of victims."
C. "Manmade disasters are intentional only."
D. "Emergencies are caused by acts of nature or emerging diseases."

Rationale: A is incorrect because disasters may be natural or man-made. C is incorrect because

man-made disasters are either accidental or intentional. D is incorrect because natural
disasters, not emergencies, are caused by acts of nature or emerging diseases.

78. An emergency room nurse is working when there is a bioterrorism attack in the city. Which
of the following statements is a correct with regard to injuries or symptoms associated with
a bioterrorism attack?
A. The main purpose of biological weapon use is contained devastation.
B. It is not uncommon for the results of a biological attack to be made known several
hours or days after the attack.
C. Biological attacks are usually known right away.
D. Detection is easy as clients go to a number of different health care facilities.

Rationale: Biological terrorism is the use of etiological agents (disease) to cause harm or kill a
population, food, and/or livestock. A is incorrect because the main purpose of biological
weapon use is mass devastation. C is incorrect because a biological attack may not be known
for several hours or days after the attack. D is incorrect because detection is difficult as clients
go to a number of different health care facilities for treatment.

79. Michael works as a triage nurse, and four clients arrive at the emergency department at the
same time. List the order in which he will assess these clients from first to last.
1. A 50-year-old female with moderate abdominal pain and occasional vomiting.
2. A 35-year-old jogger with a twisted ankle, having a pedal pulse and no deformity.
3. An ambulatory dazed 25-year-old male with a bandaged head wound.
4. An irritable infant with a fever, petechiae, and nuchal rigidity.

A. 1, 2, 3, 4
B. 2, 1, 3, 4
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C. 4, 3, 1, 2
D. 3, 4, 2, 1

Rationale: An irritable infant with fever and petechiae should be further assessed for other
meningeal signs. The patient with the head wound needs additional history and assessment for
intracranial pressure. The patient with moderate abdominal pain is uncomfortable, but not
unstable at this point. For the ankle injury, a medical evaluation can be delayed 24 - 48 hours if
necessary.

80. A 65-year-old patient arrived at the triage area with complaints of diaphoresis, dizziness,
and left-sided chest pain. This patient should be prioritized into which category?
A. Non-urgent.
B. Urgent.
C. Emergent.
D. High urgent.

Rationale: Chest pain is considered an emergent priority, which is defined as potentially life-
threatening. Option B: Clients with urgent priority need treatment within 2 hours of triage.
Option A: Non-urgent conditions can wait for hours or even days. Option D: High urgent is not
commonly used; however, in 5-tier triage systems, High urgent patients fall between emergent
and urgent in terms of the time elapsing prior to treatment.

81. Which of these is not classified as a Category A biologic agent?

A. Staphylococcus enterotoxin B (SEB).
B. Clostridium botulinum toxin (botulism).
C. Bacillus anthracis (anthrax).
D. Francisella tularensis (tularemia).

Rationale: Staphylococcus enterotoxin B (SEB) belongs to the category B priority pathogen.

82. A 15-year-old male client was sent to the emergency unit following a small laceration on the
forehead. The client says that he can't move his legs. Upon assessment, respiratory rate of
20, strong pulses, and capillary refill time of less than 2 seconds. Which triage category
would this client be assigned to?
A. Black.
B. Green.
C. Red.
D. Yellow.

Rationale: The client is possibly suffering from a spinal injury but otherwise, has a stable status
and can communicate so the appropriate tag is YELLOW.
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83. The nurse has been assigned the role of triage nurse after a weather-related disaster. What
is the priority action of the nurse?
A. Call in additional staff to assist with care of the victims.
B. Splint fractures and clean and dress lacerations.
C. Perform a rapid assessment of clients to determine priority of care.
D. Provide psychological support to staff and family members.

Rationale: The triage nurse classifies victims of the explosion into priority of care based on
illness or injury severity. Calling in additional staff more likely would be done by the hospital
incident commander or designee. Physical care is provided to victims after triage occurs.
Psychological support should be an ongoing part of the disaster plan but is not included in
triage responsibilities; this ensures that the greatest good is provided to the greatest number of
people.

84. An Emergency Department nurse is informed of a nearby bombing at the office building.
This nurse needs to be aware of the principles of triage and decontamination. In which zone
does decontamination usually occur?
A. In the hot zone
B. In the warm zone
C. In the cold zone
D. In the artic zone

Rationale: The site of the disaster where a weapon was released or where the contamination
occurred is called the hot zone. It is considered contaminated, and only those persons in the
appropriate personal protective equipment may enter this zone. The warm zone is adjacent to
the hot zone. Another name for this area is the control zone. This area is where the
decontamination of victims or triage and emergency treatment takes place. The cold zone is
considered to be the safe zone.

85. A chemical plant has had a chemical leak. The nurse manager in the local emergency room
receives information that this disaster is assigned a status of Level II, which indicates:
A. Local emergency response teams can manage the situation.
B. Regional efforts and aid from surrounding communities can manage the situation.
C. Statewide or federal assistance is required.
D. The area must be evacuated immediately.

Rationale: Level II disasters indicate that regional efforts and aid from the surrounding
communities will successfully manage the situation.
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86. The client with a temperature of 94˚F is being treated in the ED. Which intervention should
the nurse implement to directly elevate the client's temperature?
A. Remove the client's clothing.
B. Place a warm air blanket over the client.
C. Have the client change into a hospital gown.
D. Raise the temperature in the room.

Rationale: The warm air blanket blows warm air over the client and is an active warming
method.

87. A hospital committee is in the preparatory stages of developing an emergency operations

plan (EOP). Which of the following actions take place during the post-incident response of
an emergency operations plan?
A. It is decided when the facility goes from disaster response to daily activities.
B. Practice drills are conducted for the community and facility.
C. A critique and debriefing occur for all involved immediately and at later dates.
D. Replacement of resources occurs in the facility.

Rationale: A post-incident response includes critiquing and debriefing all parties involved
immediately and at later dates.

88. A 40-year-old male patient who was at the site of a workplace explosion that is considered a
disaster area has suffered second- and third-degree burns to 65% of his body, but he is
conscious. This person would be triaged as:
A. Green
B. Yellow
C. Red
D. Black

Rationale: The purpose of triaging in a disaster is to do the greatest good for the greatest
number of people. This patient is triaged as black.

89. The ED receives a client involved in a motor-vehicle accident. The nurse notes a large
hematoma on the right flank. Which intervention should the nurse implement first
A. Insert an indwelling urinary catheter.
B. Take the vital signs every 15 minutes.
C. Monitor the skin turgor every hour.
D. Mark the edges of the bruised area.
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Rationale: Vital signs should be taken frequently to assess for covert bleeding. The hematoma
in the flank area may indicate the presence of trauma to the kidney. Because of the large
amount of blood flow through the kidney, hemorrhage is a high risk.

90. The ED nurse is completing the initial assessment on a client who becomes unresponsive.
Which intervention should the nurse implement first?
A. Assess the rate and site of the intravenous fluid.
B. Administer an ampule of sodium bicarbonate.
C. Assess the cardiac rhythm shown on the monitor.
D. Prepare to cardiovert the client into sinus rhythm.

Rationale: The rhythm on the monitor should be assessed. Many clients who become
unresponsive have a lethal rhythm requiring defibrillation immediately.

91. A patient has been exposed to anthrax by inhalation. Which of the following signs and
symptoms would indicate that the patient is in the second stage of infection?
A. Headache
B. Vomiting
C. Syncope
D. Cyanosis

Rationale: The second stage of anthrax infection by inhalation includes severe respiratory
distress, including stridor, cyanosis, hypoxia, diaphoresis, hypotension, and shock. The first
stage includes flu-like symptoms.

92. The ED nurse is caring for the client who has taken an overdose of cocaine. Which
intervention should the nurse delegate to the unlicensed assistive personnel (UAP)
A. Evaluate the airway and breathing.
B. Monitor the rate of intravenous fluids.
C. Place the cardiac monitor on the client.
D. Transfer the client to the intensive care unit.

Rationale: The UAP can attach leads to the client for the cardiac monitor.

93. The nurse is aware that the patient suspected of being exposed to the smallpox virus is
contagious:
A. Immediately after exposure
B. Only when pustules form
C. After a rash appears
D. With a body temperature of 38° C
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Rationale: A patient is contagious after a rash that develops on the face, mouth, pharynx, and
forearms initially.

94. A patient who is a victim of a terrorist attack involving a chemical agent presents to the
emergency department with visual disturbances, nausea, vomiting, forgetfulness, and
irritability. The nurse suspects this patient has been exposed to which of the following
chemical agents?
A. Nerve
B. Pulmonary
C. Vesicants
D. Blood

Rationale: Nerve agent exposure results in visual disturbances, nausea, vomiting, forgetfulness,
irritability, and impaired judgment.

95. After being exposed to a dose of more than 5000 rads of radiation during a terrorist
bombing, the patient's skin will show which of the following manifestations within a few
days to months?
A. Erythema
B. Recurring erythema
C. Desquamation
D. Necrosis

Rationale: Necrosis of the skin becomes evident within a few days to months at doses of more
than 5000 rads. With 600 to 1000 rads, erythema occurs; it can disappear within hours and
then reappear. At greater than 1000 rads, desquamation (radiation dermatitis) of the skin
occurs.

96. A 44-year-old male patient has been exposed to radiation. Which of the following is the
most accurate statement regarding decontamination?
A. Alcohol and iodine scrubs are necessary.
B. Soap and water scrubs are necessary.
C. The patient should be assessed in the emergency room before decontamination.
D. The patient's clothing is double bagged and stored inside the facility.

Rationale: The majority of patients can be safely decontaminated with soap and water. Waste
is controlled through double bagging and plastic-lined containers outside of the facility. Triage
outside the hospital is the most effective means of preventing contamination of the facility
itself.
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97. A patient has been transported to an emergency room from the scene of a terrorist
chemical attack. The emergency room staff members have been trained to follow steps that
decrease the risk of secondary exposure to a chemical used in a terrorist attack. Which of
the following initial steps must be implemented?
A. Decontamination
B. Universal precautions
C. Defusing
D. Triaging

Rationale: Decontamination must be implemented to remove the accumulated contaminants

and decrease the risk of secondary exposure and contamination.

98. The nurse is caring for a client in the ED with abdominal trauma who has had peritoneal
lavage. Which intervention should the nurse include in the plan of care?
A. Assess for the presence of blood, bile, or feces.
B. Palpate the client for bilateral femoral pulses.
C. Perform Leopold's maneuver every eight (8) hours.
D. Collect information on the client's dietary history.

Rationale: A diagnostic peritoneal lavage is performed to assess the presence of blood, bile,
and feces from internal bleeding induced by injury. If any of these are present, surgery should
be considered to explore the extent of damage and repair of the injury.

99. The ED nurse is caring for a client diagnosed with multiple rib fractures. Which data should
the nurse include in the assessment?
A. Level of orientation to time and place.
B. Current use and last dose of medication.
C. Symmetrical movement of the chest.
D. Time of last meal the client ate.

Rationale: When a client suffers from multiple rib fractures, the client has an increased risk for
flail chest. The nurse should assess the client for paradoxical chest wall movement and, if
respiratory distress is present, for pallor and cyanosis.

100. The ED nurse is caring for a client who suffered a near-drowning. Which expected
outcome should the nurse include in the plan of care for this client?
A. Maintain the client's cardiac function.
B. Promote a continued decrease in lung surfactant.
C. Warm rapidly to minimize the effects of hypothermia.
D. Keep the oxygen saturation level above 93%.
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Rationale: The oxygen level needs to be maintained greater than 93%. The client needs as
much support as necessary for this. Mechanical ventilation with peak end-expiratory pressure
(PEEP) and high oxygen levels may be needed to achieve this goal.