Chapter 65 My Nursing Test Banks

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Chapter 65

Question 1

Type: MCMA

Law enforcement authorities have notified the emergency department that several people who have been exposed to nerve gas will be arriving. The nurse manager alerts the department nursing staff to expect patients with which assessment findings?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Muscle pain

2. Flaccid paralysis

3. Shortness of breath

4. Miosis

5. Rhinorrhea

Correct Answer: 3,4,5

Rationale 1: Muscle pain is typically not a symptom of nerve gas exposure.

Rationale 2: Flaccid paralysis is not a symptom of nerve gas exposure. Muscle fasciculations are.

Rationale 3: Almost all people affected by a nerve agent have shortness of breath.

Rationale 4: Miosis is defined as constricted pupils and is one of the most reliable signs of nerve poisoning.

Rationale 5: Almost all people affected by a nerve agent have rhinorrhea, or a runny nose.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 65-2

Question 2

Type: MCMA

The emergency department has been notified of a possible Category A biologic exposure in a rural community. When preparing staff for these patients, the nurse manager explains care for victims of which agents?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Botulism

2. Anthrax

3. Plague

4. Tularemia

5. Salmonella

Correct Answer: 1,2,3,4

Rationale 1: Botulism is a Category A biologic agent.

Rationale 2: Anthrax is a Category A biologic agent.

Rationale 3: Plague is a Category A biologic agent.

Rationale 4: Tularemia is a Category A biologic agent.

Rationale 5: Salmonella is a Category B biologic agent.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 65-2

Question 3

Type: MCSA

A patient is brought into the emergency department after an acute exposure to radiation from the local atomic power plant. The patient has skin burns on the face, arms, and neck. The nurse implements which priority intervention?

1. Prepare to administer a blood transfusion.

2. Determine amount of radiologic exposure.

3. Begin antibiotic therapy.

4. Provide support for the onset of hypotension and diarrhea.

Correct Answer: 2

Rationale 1: Blood transfusion may be necessary but is not the priority intervention.

Rationale 2: Most hospitals have Geiger counters to determine the presence or absence of radiation in the environment. The Geiger counter can be used to help assess the dose of radiation the patient received.

Rationale 3: Antibiotic therapy may be necessary but is not the priority intervention.

Rationale 4: Hypotension and diarrhea may develop, but this is not the priority intervention.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 65-2

Question 4

Type: MCSA

A patient is brought into the emergency department after being exposed to over 1,000 rads of radiation. Which intervention will take priority in the care of this patient?

1. Administer sedatives and analgesics.

2. Provide antibiotic therapy.

3. Prepare intravenous fluids and order a bland diet.

4. Provide antiemetics.

Correct Answer: 1

Rationale 1: The patient exposed to over 1,000 rads of radiation will have central nervous system symptoms. Death will occur within hours to days. Care involves administering sedatives and analgesics to control seizures and anxiety.

Rationale 2: Antibiotic therapy is indicated for the hematopoietic symptoms of the illness phase of acute radiation syndrome.

Rationale 3: Intravenous fluids and a bland diet would be indicated for the gastrointestinal symptoms of the illness phase of acute radiation syndrome.

Rationale 4: Antiemetics are indicated for the gastrointestinal symptoms of the illness phase of acute radiation syndrome.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 65-2

Question 5

Type: MCSA

A patient tells the nurse that he thought that he would feel better because it has been a few days since his radiation exposure, but he still feels weak and tired. What is the nurses best response to this patient?

1. Increasing your activity will help with the feelings of fatigue.

2. After your strength returns, you might have diarrhea.

3. This means that your body is healing.

4. The weak and tired feelings will continue for a while longer.

Correct Answer: 4

Rationale 1: Increasing activity will not help with the fatigue caused by this syndrome.

Rationale 2: Diarrhea will precede the feelings of fatigue.

Rationale 3: This feeling of fatigue does not mean that the patients body is healing.

Rationale 4: During the prodromal phase of acute radiation syndrome, the gastrointestinal symptoms of nausea, vomiting, and diarrhea usually resolve within 2 days, but the fatigue and malaise often continue.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 65-2

Question 6

Type: MCSA

The hospital has activated its incident command system (HICS) and is currently triaging patients and determining the extent of injuries and casualties. The nurse would refer calls from the media to which person?

1. The safety and security officer

2. The liaison officer

3. The public information officer

4. The incident commander

Correct Answer: 3

Rationale 1: The safety and security officer monitors and has authority over the safety of rescue operations and hazardous conditions.

Rationale 2: The liaison officer is the contact person for representatives of other agencies, such as the fire department and police.

Rationale 3: The public information officer provides information to the media, releases other information as indicated, and assists with communication.

Rationale 4: The incident commander organizes and directs the emergency operations center and gives overall direction for the hospital operations.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 65-5

Question 7

Type: MCSA

The hospital incident command system (HICS) has been activated following a multivehicle accident. Nurses are moving ambulatory patients to one section of the emergency department. These patients will be assigned which START triage category?

1. Yellow

2. Green

3. Black

4. Red

Correct Answer: 2

Rationale 1: Patients with major illness or injury who require treatment within 30 to 60 minutes are assigned the yellow category.

Rationale 2: The walking wounded are assigned to the green nonurgent category.

Rationale 3: The black category is used for those who are dead or are expected to die.

Rationale 4: Patients with life-threatening injury, airway issues, or surgical issues that can be corrected in the ED are assigned the red

category.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 65-3

Question 8

Type: MCSA

Because of high demand during a disaster, the pharmacy has run out of normal saline intravenous solutions and the blood bank is down to 10 units of type O+ blood. The directors of these services would contact which section of the hospital incident command system (HICS) to obtain these supplies?

1. Finance

2. Logistics

3. Planning

4. Operations

Correct Answer: 2

Rationale 1: Finance provides the funding for the operation and assists with recovery of costs.

Rationale 2: Logistics provides the hospital with materials to meet all ongoing needs, such as food, medication, shelter, and other supplies.

Rationale 3: The planning section is responsible for providing a situation status report to hospital workers every 4 to 6 hours and interacts with operations to establish plans for medical staff rotation.

Rationale 4: Operations covers the work of medical care.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 65-5

Question 9

Type: MCSA

During a natural disaster, the Strategic National Stockpile was deployed and supplies were used to treat patients. Now that the initial medical and nursing response is over, who is responsible for retrieving the remnants of the 12-hour push packs?

1. The Technical Advisory Response Unit

2. The vendors who supply the materials in the packs

3. Centers for Disease Control personnel

4. The nurses who provided emergency care to the victims

Correct Answer: 1

Rationale 1: The Technical Advisory Response Unit is a team of advisors who assist in recovering the support equipment and cargo containers used to transport the 12-hour push packs. They also recover unused Strategic National Stockpile assets and materials.

Rationale 2: The vendors are the organizations who provide the supplies within the 12-hour push packs and are not responsible for retrieving unused supplies.

Rationale 3: Centers for Disease Control personnel are not responsible for retrieving unused supplies.

Rationale 4: The nurses who provided the emergency care are not responsible for the removal or retrieval of the 12-hour push pack unused contents.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 65-6

Question 10

Type: MCSA

The nurse is interested in learning how to become a disaster relief nurse. What should the nurse consider prior to joining the Disaster Medical Assistance Team (DMAT) program?

1. The nurse must be licensed to practice nursing in the state of the disaster.

2. The nurse must provide and pay for his or her own personal gear, including a sleeping bag.

3. The nurse must be willing to be a volunteer, as the positions are unpaid.

4. The nurse must be willing to pay for his or her own travel to the disaster region.

Correct Answer: 2

Rationale 1: The nurse working on this team is considered a federal employee, so any license or certification the nurse holds will be automatically recognized in all 50 states.

Rationale 2: Each DMAT member is required to provide certain personal gear, such as eye and ear protection, leather work gloves, a canteen, a sleeping bag, a camping knife, hand cleanser gel, and toilet paper.

Rationale 3: Members of the DMAT are volunteers; however, while deployed, they are considered federal employees and are paid wages.

Rationale 4: Travel to the disaster region is reimbursed.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 65-6

Question 11

Type: MCSA

The nurse who is a member of a Disaster Medical Assistance Team (DMAT) has the remains of several victims of a disaster to be identified and collected. Which group should the nurse contact for this service?

1. Disaster Mortuary Operations Response Teams

2. Department of Health and Human Services employees

3. Centers for Disease Control employees

4. Office of Environmental Protection employees

Correct Answer: 1

Rationale 1: Disaster Mortuary Operations Response Teams are groups of volunteers who are responsible for morgue-related operations, remains identification, and family notification.

Rationale 2: The Department of Health and Human Services is not a participant in disaster relief activities.

Rationale 3: The Centers for Disease Control is not a participant in disaster relief activities.

Rationale 4: The Office of Environmental Protection is not responsible for these services.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 65-6

Question 12

Type: MCSA

Facilitators of a critical incident stress debriefing are instructing the nurses on ways to cope with the stress created by providing disaster care. The nurses are participating in which phase of the debriefing session?

1. Reaction

2. Reentry

3. Fact

4. Teaching

Correct Answer: 4

Rationale 1: During the reaction phase, the participants identify their own emotional reactions to the most traumatic aspects of the event.

Rationale 2: During reentry the session is summarized and questions are answered.

Rationale 3: In the fact phase each participant describes the event from his or her own point of view.

Rationale 4: During the teaching phase of the critical incident stress debriefing session, the facilitators of the session provide education regarding adaptive coping mechanisms.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 65-7

Question 13

Type: MCSA

The nurse is admitting the fourth patient in 2 days who is experiencing malaise, high fever, and headache. All patients attended a local air show the previous weekend. Which nursing action is necessary?

1. Discuss the need to contact public health authorities regarding the similarity of the cases.

2. Plan to place the patients in the same room.

3. Ask the patients for permission to talk with family members regarding other symptoms.

4. Assess the patients for what foods they ate while at the air show.

Correct Answer: 1

Rationale 1: The nurse should be alert to illness patterns that could indicate an unusual infectious disease outbreak. Indicators of a biologic agent release include increased disease incidence among people who attended the same event. The nurse should discuss the need to contact public health authorities regarding the similarity of the cases.

Rationale 2: Placing the patients in the same room may or may not be appropriate.

Rationale 3: The family members of the patients do not need to be assessed at this time.

Rationale 4: The foods ingested during the air show may not provide enough information about the patients exposure.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 65-2

Question 14

Type: MCSA

A group of workers arrives at the hospital after being exposed to chemicals during an industrial accident. The nurse would prepare to supervise decontamination in which zone?

1. Warm

2. Red

3. Cold

4. Green

Correct Answer: 1

Rationale 1: Actual decontamination takes place in the warm zone.

Rationale 2: The red or hot zone is where people wait to be decontaminated.

Rationale 3: The cold zone is the support zone. No one is allowed into the cold zone until decontamination has been performed.

Rationale 4: The green zone is equivalent to the cold zone. No one is allowed into the cold zone until decontamination has been performed.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 65-4

Question 15

Type: MCSA

The nurse is assessing victims of a building collapse. Ambulances are nearby and there is a shelter set up with carts, chairs, tables, and refreshments for the victims. The nurse is most likely working within which decontamination zone?

1. Cold

2. Warm

3. Control

4. Hot

Correct Answer: 1

Rationale 1: The cold zone is considered the safe zone. It is adjacent to the warm zone and is the area where a more in-depth triage of victims would occur. It includes the clean treatment area, the clean evacuation area, and staging areas for personnel.

Rationale 2: The warm zone, or control zone, is adjacent to the hot zone. This area is where decontamination of victims or triage and emergency treatment take place.

Rationale 3: The control zone, or warm zone, is where decontamination of victims or triage and emergency treatment take place.

Rationale 4: The site of the disaster where a weapon was released or contamination occurred is called the hot zone. It is considered contaminated, and only those persons in appropriate personal protective equipment may enter this zone.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 65-4

Question 16

Type: MCSA

A group of nurses are attending a meeting to discuss the outcomes and results of care provided to victims of a recent building collapse. The nurses are participating in which phase of the disaster planning process?

1. Mitigation

2. Recovery

3. Response

4. Preparedness

Correct Answer: 2

Rationale 1: Mitigation involves reducing or eliminating the consequences of a hazard or incident so that it has a limited impact on society. It is a form of prevention.

Rationale 2: Recovery involves returning the lives and the environment of those affected by the disaster to normal. This includes the nurses involved in the care of victims.

Rationale 3: Response involves the actions taken to reduce or eliminate the impact of the disaster.

Rationale 4: Preparedness requires that those who may be affected by the disaster have the equipment and resources needed to increase the chances of survival and reduce losses related to the disaster.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 65-2

Question 17

Type: MCMA

The nurse is planning to attend a program to learn how to respond to mass casualty incidents. The nurse anticipates this program will address which core competencies of emergency and disaster preparedness for nurses?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Creative problem-solving skills

2. Adherence to standard protocols and policies

3. Emergency communication skills

4. Understanding of personal limitations

5. Identification of emergency situations

Correct Answer: 1,3,4,5

Rationale 1: Applying creative problem solving is a core competency of emergency and disaster preparedness for nurses.

Rationale 2: Emergency and disaster preparedness core competencies emphasize flexible thinking rather than adherence to policies used in nondisaster situations.

Rationale 3: Communication skills in emergency response is a nursing core competency.

Rationale 4: Competency in emergency and disaster nursing includes identifying the limitations of ones own knowledge and skills.

Rationale 5: Recognizing deviations from the norm that might indicate an emergency is a core competency expected of nurses.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 65-2

Question 18

Type: MCSA

A mass casualty accident has occurred. The first patient the nurse receives has a color code of red. What is the nurses disposition of this patient?

1. Send the patient home.

2. Plan to evaluate this patient in the next 30 minutes to 1 hour.

3. Intervene immediately in this patients care.

4. Allow the patient to die.

Correct Answer: 3

Rationale 1: A green tag would indicate that the patient can be self-treated. Such a patient may come to the ED by personal vehicle.

Rationale 2: A patient who should be seen in the next 30 minutes to 1 hour is tagged with a yellow tag.

Rationale 3: Emergent or red-tagged patients have life-threatening injuries that should be addressed immediately.

Rationale 4: A black/expectant code means the patient is expected to die from the injuries.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 65-3

Question 19

Type: FIB

A patient has been prescribed 400 mg ciprofloxacin IV for anthrax prophylaxis. The pharmacy has sent a 1 gram vial of ciprofloxacin to the nursing unit to be diluted with 10 mL of sodium chloride. The nurse should administer ____ mL.

Standard Text:

Correct Answer: 4

Rationale : 1 gram is equal to 1000 mg.
1000 mg/10 mL = 400 mg/x mL
x = 4 mL

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 65-2

Question 20

Type: FIB

After an anthrax exposure, the health care provider orders doxycycline 100 mg PO. The label on the bottle of doxycycline oral powder states to reconstitute with sterile water to prepare a concentration of 0.025 g/5 mL. The nurse should prepare to administer ______ mL to the patient.

Standard Text:

Correct Answer: 20

Rationale : First, it is necessary to change the grams to milligrams.
1000 mg = 1 g
0.025 1000 = 25 mg
There are 25 mg of doxycycline in each 5 mL of liquid.
25 mg/5 mL = 100 mg/x mL
x= 20 mL

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 65-2

Question 21

Type: MCSA

The nurse is using the Simple Triage and Rapid Treatment (START) system to triage patients brought to the hospital after a tornado. Which triage designation has the nurse correctly assigned?

1. Red tag for a 67-year-old male complaining of chest pain; heart rate 120 beats/min, blood pressure 100/68 mmHg, respiratory rate 20 breaths/min

2. Red tag for a 27-year-old woman presenting with a respiratory rate of 36 breaths/min and capillary refill of 4 seconds

3. Yellow tag for a 58-year-old woman able to walk on her own and saying over and over, I dont know what happened

4. Red tag for a 30-year-old male with multiple chest trauma; respiratory effort minimal after airway is opened; carotid pulse faint

Correct Answer: 2

Rationale 1: Because this patients respiratory rate is below 30 and blood pressure is above 80 systolic, the patient is considered urgent and should receive a yellow tag.

Rationale 2: Patients with respiratory rates above 30 and capillary refill delayed more than 2 seconds get a red tag.

Rationale 3: Patients who have minor injuries are categorized as green. They can walk and take care of themselves.

Rationale 4: Patients who are least likely to survive or are already deceased are color coded black. Patients with no spontaneous effective respiration, even after the airway is manually opened, would receive a black tag.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 65-3

Question 22

Type: MCMA

A nurse is contributing to the disaster plan for a newly established health care clinic in a rural area. Which scenarios would the nurse include in planning for human-generated disasters?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. A motor vehicle crash with numerous victims

2. Widespread destruction and injury from a large tornado

3. Release of dangerous chemicals from an industrial accident

4. Terrorist attack on a dam resulting in widespread flooding

5. Influenza epidemic

Correct Answer: 1,3,4

Rationale 1: If the number of victims is sufficient to overwhelm the resources of the clinic, it is considered a disaster. Motor vehicle crashes are human-generated.

Rationale 2: Tornado damage and injury is a natural disaster.

Rationale 3: Chemical release in an industrial accident is a human-generated event.

Rationale 4: Terrorism in any form is a human-generated event.

Rationale 5: Influenza epidemics are health emergencies that are not considered human-generated.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 65-1

Question 23

Type: MCSA

The nurse manager is working on a committee to revise a hospitals emergency preparedness plan. What is the first step of this work?

1. Conduct a hazard risk analysis.

2. Write a basic plan that can be expanded as time permits.

3. Describe functional annexes.

4. Develop hazard-specific annexes.

Correct Answer: 1

Rationale 1: The committee should first assess their environment for potential risks.

Rationale 2: The basic plan cannot be written until another step is completed.

Rationale 3: Functional annexes cannot be developed until another step is completed.

Rationale 4: Hazard-specific annexes cannot be developed until another step is completed.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 65-2

Question 24

Type: MCMA

The nurse is working with a committee to revise the hospitals disaster preparedness plan. Which information will the basic plan include?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. A map of the area served by the hospital

2. The number and location of nursing homes in the area

3. The number of private homes in the immediate area of the hospital

4. The presence of an industrial area south of the hospital

5. The geographical area generally served by the hospital

Correct Answer: 1,2,4,5

Rationale 1: Maps are useful information in case of an emergency and are included in the basic plan.

Rationale 2: The basic plan should identify the presence and location of special populations in the area.

Rationale 3: This information is not likely to be important during a disaster and is not included in the basic plan.

Rationale 4: The basic plan should include a list of specific hazards in the area, such as chemical and biologic hazards.

Rationale 5: The basic plan should describe the geographic limits of the hospitals general service area.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 65-2

Question 25

Type: MCSA

The nurse decides to respond to a disaster in another city. When arriving at the scene, what should the nurse do first?

1. Begin treating triaged patients.

2. Survey the scene for personal safety.

3. Locate the check-in station.

4. Begin triaging patients.

Correct Answer: 3

Rationale 1: The nurse should not begin treating patients immediately.

Rationale 2: Scene survey for personal safety is very important, but it is not the priority action.

Rationale 3: The nurse should check in with authorities at the scene who will deploy services as needed.

Rationale 4: The nurse should not immediately begin triaging patients.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 65-2

Question 26

Type: MCSA

The emergency department (ED) is overwhelmed with victims of a disaster who are arriving in private vehicles. Many are seriously injured. What action should be taken by the nurse manager?

1. Notify law enforcement to divert traffic away from the hospital.

2. Provide quick instruction to housekeeping staff on safe ways to help patients out of the cars.

3. Contact the incident commander and ask that first responders be sent to the hospital.

4. Tell nurses that they should focus solely on those patients who can get into the hospital with no staff assistance.

Correct Answer: 3

Rationale 1: This is not an appropriate action and is not the help needed by the ED staff.

Rationale 2: Serious damage is possible during extrication, and this duty should not be delegated to those who are not trained appropriately.

Rationale 3: First responders have training in extrication. This extrication should be done by trained individuals.

Rationale 4: People will arrive at the hospital with the expectation that they will be helped out of the car, and the nurse manager should try to facilitate their safe extrication.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 65-2

Question 27

Type: MCSA

Which information would the nurse expect to be part of an effective initial disaster preparedness plan for a major metropolitan hospital?

1. Expect early notification of the numbers, types, and severities of casualties that can be expected.

2. The most seriously wounded victims can be expected to arrive first.

3. The initial response will be conducted by in-house staff.

4. Triage and decontamination will be conducted in the field before transport.

Correct Answer: 3

Rationale 1: Often the hospital is first aware of a disaster when casualties begin arriving by private vehicle.

Rationale 2: Often the first victims to arrive at the hospital are those who come by private or public transportation or who walk from the scene.

Rationale 3: The first response to disaster is carried out by the staff working at the time it occurs. On-call resources take time to arrive.

Rationale 4: Many victims will likely bypass triage and decontamination and go directly to the hospital for care.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 65-2

Question 28

Type: MCSA

A hospital has been notified that a tornado injured numerous people in a neighboring town and the hospital may receive some victims. How should the hospital administration respond?

1. Immediately implement the hospitals incident command system.

2. Wait until the first victims arrive to implement the hospital incident command system.

3. Implement the positions and functions most likely to be required by the situation and reassess once patients arrive.

4. Notify the emergency department that a drill is possible.

Correct Answer: 3

Rationale 1: There may be no need for this implementation. Another option is indicated.

Rationale 2: Waiting until victims arrive does not allow sufficient time for the system to gear up for an influx of patients.

Rationale 3: This scenario does not provide enough information to justify full-blown implementation of the HICS.

Rationale 4: This is not a drill situation. The emergency department should be notified that there is a potential for an influx of patients.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 65-2

Question 29

Type: MCMA

The nurse has been assigned to monitor staff wearing personal protective equipment (PPE) during a disaster. The nurse would monitor for which types of distress?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Hypothermia

2. Dehydration

3. Inability to communicate

4. Claustrophobia

5. Vision limitation

Correct Answer: 2,3,4,5

Rationale 1: PPE requires a completely closed environment, which may cause hyperthermia. Hypothermia is not typically an issue.

Rationale 2: PPE limits the ability to drink and increases insensible losses. Dehydration is a serious consideration.

Rationale 3: PPE limits the ability to communicate, which can be a serious problem when working in a disaster situation.

Rationale 4: People who cannot tolerate enclosed spaces may have serious, panic-type problems when wearing PPE.

Rationale 5: Wearing PPE can increase risk of injury because vision is limited by the headgear that must be worn.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 65-4

Question 30

Type: MCMA

The emergency department nurse manager is working with the physical plant manager to identify decontamination zones as part of the hospitals emergency preparedness plan. Which concepts should be considered in this planning?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. More than one decontamination area should be chosen.

2. The area should be large enough to accommodate three different zones for decontamination.

3. The site and zones should be painted on the hospital parking lot for easy identification at the time of need.

4. The red zone area should be large enough to accommodate triage activities.

5. There should be a method to limit entry to the cold zone.

Correct Answer: 1,2,4,5

Rationale 1: Multiple potential decontamination sites should be chosen. As the actual site should be downwind from the hospital, weather conditions will determine the appropriate site when the need for it arises.

Rationale 2: The area should be large enough to contain a hot zone, a warm zone, and a cold zone.

Rationale 3: The placement of this area will vary according to weather.

Rationale 4: Triage is conducted in the red zone to determine which patients require immediate attention.

Rationale 5: No one is allowed into the cold zone unless they have been decontaminated. It is necessary to secure this zone from access.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 65-4

Question 31

Type: MCMA

A smallpox outbreak has been identified, and supplies have been requested from vendor-managed inventory. The nurse manager receiving these supplies would anticipate providing which material from the hospitals internal inventory?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Examination gloves

2. Diluent for the vaccine

3. Transfer needles

4. Sharps containers

5. Adhesive bandages

Correct Answer: 1,4,5

Rationale 1: Gloves will be supplied from the hospitals internal inventory.

Rationale 2: Diluent will be shipped with the vaccine.

Rationale 3: Transfer needles will be sent with the vaccine.

Rationale 4: The hospital is expected to supply sharps containers.

Rationale 5: The hospital is expected to supply adhesive bandages.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 65-6

Question 32

Type: MCMA

The nurse manager is determining whether a recent situation involving the injury and death of multiple patients in a gun battle should be classified as a critical incident. Which components of a critical incident should the nurse consider?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Have any of the staff involved asked for critical incident interventions?

2. Was the incident abnormal in this environment?

3. Have any of the staff involved behaved abnormally since the incident?

4. Did the incident disrupt the emotional culture of the ED?

5. Has there been evidence of inability to cope with severely injured patients since the incident?

Correct Answer: 2,4,5

Rationale 1: Staff members involved in these incidents may need intervention and not be willing to ask for it. They may not realize the depth of the disruption in their lives.

Rationale 2: If the staff is exposed to this kind of incident on a routine basis, critical incident stress intervention may not be necessary. If this kind of incident is rare in this ED, intervention is likely to be needed.

Rationale 3: It is the incident that is abnormal, not the response to it.

Rationale 4: Strong emotional reactions may manifest as a change in staff members ability to work together under stress.

Rationale 5: If there is evidence that the staff is unable to cope with typical events in the ED, critical incident stress interventions are likely to be necessary.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 65-7

Question 33

Type: FIB

The nurse manager has determined that critical incident stress debriefing (CISD) is necessary for staff members who provided care after a multivehicle accident that resulted in serious injury to 10 children and 8 adults. The manager should ensure that this session starts within ______ hours of the incident.

Standard Text:

Correct Answer: 72

Rationale : CISD occurs within 72 hours of the critical incident and typically lasts 2 to 3 hours.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 65-7

Question 34

Type: MCMA

The nurse manager is planning critical incident defusing for staff who provided care for patients injured in a house fire. What should be included in this planning?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Plan for each session to last 2 to 3 hours.

2. Gather groups of no more than 6 to 8 staff members.

3. Develop groups according to shift worked.

4. Emphasize strict confidentiality within the group.

5. Record level of participation in the groups.

Correct Answer: 2,4

Rationale 1: The sessions typically last 20 to 45 minutes.

Rationale 2: The group size should be limited to 6 to 8.

Rationale 3: Groups should be composed of those in similar job descriptions.

Rationale 4: The proceedings of this group should be strictly confidential.

Rationale 5: No record of the group interaction is kept.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Planning

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