Question 40

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Which statement below is INCORRECT about the yellow triage tag color in regard to a

disaster situation?

Select one:

a. A survivor With this tag color is seen after patients with the green tag color.

b. A survivor with this tag color has serious injuries that could eventually lead to

the compromise of breathing, circulation, or mental status, especially if

treatment is delayed more than an hour

c. A survivor with this tag color can have treatment delayed for an hour or less.

d. A survivor With this tag color has second priority for treatment of injuries.

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Question 39

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When attending a client with a head and neck trauma following a vehicular

accident, the nurse's initial action is to?

Select one:

a. Provide oxygen therapy

b. Do oral and nasal suctioning c, Immobilize the cervical

area d, Initiate intravenous access

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Question 38

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A triage nurse in a busy emergency department assesses a patient who complains of

6/10 abdominal pain and states. "l had a temperature of 104.60 F (40_30 C) at

home." The nurse's first action should be to

Select one:

a. tell the patient that it may be several hours before being seen by the doctor.

b. ask the health care provider to order a nonopioid analgesic medication for

the patient.

c. obtain a clean-catch urine for urinalysis.

d. assess the patienfs current vital signs.

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Questm37

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Which finding indicates that fluid resuscitation has been successful for a

client With a burn injury?

Select one:

a. Hematocrit = 60%

b. Heart rate = 130 beats/min

c. Urine output 50 mL/hr

d. Increased peripheral edema

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Question 36

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The client who is burned is drooling and having difficulty swallowing. Which action

will the nurse take first?

Select one:

a. Assesses level of consciousness and pupillary reactions

b. Auscultates breath sounds over the trachea and mainstem bronchi

c. Ascertains the time food or liquid was last consumed

d. Measures abdominal girth and auscultates bowel sounds

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A 1 5-year-old male client arrives at the emergency department. He is conscious.

coherent, and ambulatory, but his shirt and pants are covered with blood. He and his

hysterical friends are yelling and trying to explain that they were goofing around and

he got poked in the abdomen with a stick. Which of the following comments should

be given first consideration?

Select one:

a. "He's a diabetic, so he needs attention right away."

b. "He pulled the stick out, just now, because it was hurting him."

c. "There was a lot of blood and we used three bandages."

d. "The stick was really dirty and covered

With mud."

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Question 34

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A client arrives at the emergency department who suffered multiple injuries from a

headon car collision. Which of the following assessment should take the highest

priority to take?

Select one:

a. Irregular pulse

b. Ecchymosis in the flank area

c. A deviated trachea

d. Unequal pupils

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Question 33

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Which finding is characteristic during the emergent period after a deep full-

thickness burn injury?

Select one:

a. Urine output of 10 ml-/hr

b. Foul-smelling discharge from wound

c. Pain at site of injury

d. Blood pressure of 170/100 mm Hg

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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?

Select one:

a. High urgent

b. urgent

c. Emergent

d. Non-urgent
Question 31

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The client with a new burn injury asks the nurse why he is receiving

intravenous cimetidine (Tagamet). What is the nurses best response?

Select one:

a. "This drug will help prevent kidney damage."

b. "Tagamet can help prevent hypovolemic shock."

c. "This Will help prevent stomach ulcers."

d. 'Tagamet Will stimulate intestinal movement!

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Question 30

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The client has a large, burned area on the right arm. The burned area appears pink, has

blisters, and is very painful. How will the nurse categorize this injury?

Select one:

a. Deep Partial-thickness b, Full-thickness

c. Deep Full-thickness d, Superficial Partial-thickness

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Question 29

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Michael works as a triage nurse, and four clients arrive at the emergency

department at the same time. Who must receive the highest priority?

Select one:

a. An irritable infant with a fever, petechiae. and nuchal rigidity

b. A 35-year-old jogger with a twisted ankle, having a pedal pulse, and no

deformity

c. An ambulatory dazed 25-year-old male with a bandaged head wound

d. A 50-year-old female with moderate abdominal pain and occasional vomiting

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Question 28

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The wounded Victim is unable to walk, respiratory rate is absent but When airway is

repositioned breathing is noted. The wounded victim is assigned what tag color?

Select one:

a. Green

b. Red

c. Yellow

d. Black

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Question 27

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A client who is admitted after a thermal burn injury has the following vital signs:

blood pressure, 70/40; heart rate, 140 beats/min; respiratory rate, 25/min, He is pale

in color, and it is difficult to find pedal pulses. Which action will the nurse take first?

Select one:

a. Obtain an electrocardiogram (ECG)

b. Obtain a complete blood count (CBC)

c. Check the pulses using a Doppler device

d. Start intravenous fluids

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Which type of fluid should the nurse expect to prepare and administer as fluid

resuscitation during the emergent phase of burn recovery?

Select one:

a. Packed red blood cells

b. Crystalloids

c. Fresh-frozen plasma u d. Colloids

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 25
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A 1 5-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?

Select one:

a. Black

b. Red

c. Green

@ d. Yellow le r

o
Question 24

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A 40-year-old male client who was burned was admitted under your care. Assessment

reveals he has crackles, respiratory rate of 40/min, and is coughing up blood-tinged

sputum. What action will the nurse take first?

Select one:

a. Perform chest physiotherapy

b. Place the client in an upright position

c. Administer digoxin

d. Monitor urine output

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Which of the following statements about triage is true?

Select one:

a. Triage is a detailed assessment which should lead to a clinical diagnosis

b. Triage is a low-risk activity and can be safely undertaken by junior staff

with little training

c. Triage should be undertaken as soon after arrival in the ED as possible

d. Triage only ever needs to be undertaken once in a patients ED journey

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question 22

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1 f' Flag question

A catastrophic disaster has occurred 5 miles from the hospital you are working in. The

hospital's disaster plan is activated, and the wounded are brought to the hospital.

You're helping triage the survivors. One of the wounded can walk and has minor

lacerations on the arms, hands. chest, and legs. You would place what color tag on

this survivor?

Select one:

a. Yellow

b. Green

c. Black

d. Red

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Question 21

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Which clinical manifestation indicates that the burned client is moving into the

fluid remobilization phase of recovery?

Select one:

a. Increased urine output, decreased urine specific gravity

b. Decreased peripheral pulses, slow capillary refill

c. Decreased serum sodium level, increased hematocrit

e d. Increased peripheral edema, decreased blood pressure

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