Nokea
The nurse is responding to a disaster call from home following a multivehicle motor-vehicle accident. Which action should the nurse take first?
- A. Go to the emergency department to triage the clients coming in.
- B. Assist the charge nurse to identify clients who could be discharged.
- C. Report to the command center for assignment.
- D. Pack a bag to be able to stay until the emergency is over.
Correct Answer: C
Rationale: Reporting to the command center ensures coordinated assignment per disaster protocol. Triaging, discharging, or packing are secondary.
You may also like to solve these questions
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.
Correct Answer: C
Rationale: Removing the disaster tag disrupts identification and tracking, requiring intervention. Documentation, vital signs, and attachment are appropriate.
The elderly female client with vertebral fractures who has been self-medicating with ibuprofen, a nonsteroidal anti-inflammatory drug (NSAID), presents to the ED complaining of abdominal pain, is pale and clammy, and has a P of 110 and a BP of 92/60. Which type of shock should the nurse suspect?
- A. Cardiogenic shock.
- B. Hypovolemic shock.
- C. Neurogenic shock.
- D. Septic shock.
Correct Answer: B
Rationale: NSAID-induced gastrointestinal bleeding can cause hypovolemic shock, indicated by tachycardia, hypotension, and pale, clammy skin. Cardiogenic involves cardiac failure, neurogenic involves bradycardia, and septic involves fever.
The male client was found in a parked car with the motor running. The paramedic brought the client to the ED with complaints of a headache, nausea, and dizziness and the client is unable to recall his name or address. On assessment, the nurse notes the buccal mucosa is a cherry-red color. Which intervention should the nurse implement first?
- A. Check the client’s oxygenation level with a pulse oximeter.
- B. Apply oxygen via nasal cannula at 100%.
- C. Obtain a psychiatric consult to determine if this was a suicide attempt.
- D. Prepare the client for transfer to a facility with a hyperbaric chamber.
Correct Answer: B
Rationale: Cherry-red mucosa suggests carbon monoxide (CO) poisoning; 100% oxygen via non-rebreather mask is the first intervention to displace CO. Pulse oximetry is unreliable, psychiatric consults are secondary, and hyperbaric transfer follows initial stabilization.
According to the North Atlantic Treaty Organization (NATO) triage system, which situation is considered a level red (Priority 1)?
- A. Injuries are extensive and chances of survival are unlikely.
- B. Injuries are minor and treatment can be delayed hours to days.
- C. Injuries are significant but can wait hours without threat to life or limb.
- D. Injuries are life threatening but survivable with minimal interventions.
Correct Answer: D
Rationale: NATO red (Priority 1) indicates life-threatening injuries survivable with immediate intervention (e.g., tension pneumothorax). Extensive injuries are black, minor are green, and significant but delayed are yellow.
The female client presents to the emergency department with facial lacerations and contusions. The spouse will not leave the room during the assessment interview. Which intervention should be the nurse’s first action?
- A. Call the security guard to escort the spouse away.
- B. Discuss the injuries while the spouse is in the room.
- C. Tell the spouse the police will want to talk to him.
- D. Escort the client to the bathroom for a urine specimen.
Correct Answer: D
Rationale: Escorting the client to the bathroom provides a private opportunity to assess for abuse safely. Security, discussing injuries, or mentioning police may escalate the situation.