lOMoARcPSD|36757530 Disaster nursing - nclex Disaster Nursing (Eastern Samar State University) Scan to open on Studocu Studocu is not sponsored or endorsed by any college or university Downloaded by dowi educs (pallette@cpc.cx) lOMoARcPSD|36757530 The answer is C: Red. The red tag indicates the patient must be seen first because they have life-threatening injuries, but could survive if treated quickly. The patient is still alive but there is a severe alteration in their breathing, circulation, or mental status that requires immediate medical attention. You're working as a triage nurse during a disaster situation. Based on the triage color code tags placed on each of the wounded, which tag color represents the wounded who have the highest priority of being treated first? A. Green B. Yellow C. Red D. Black The answer is C: Green tags are for patients who have MINOR injuries. If the patient can walk around they are tagged as green. Sometimes they are referred to as the "walking wounded" 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 is able to walk around and has minor lacerations on the arms, hands, chest, and legs. You would place what color tag on this survivor? A. Red B. Yellow C. Green D. Black The answer is A. This statement is INCORRECT. It should say: A survivor with this tag color is seen after patients with the RED (not green) tag color. Which statement below is INCORRECT about the yellow triage tag color in regards to a disaster situation? A. A survivor with this tag color is seen after patients with the green tag color. B. A survivor with this tag color can have treatment delayed for an hour or less. C. 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 or so. D. A survivor with this tag color has second priority for treatment of injuries. The answer is B: Red. or the next 7 questions, use the START method for adults to help triage the wounded that have been involved in a disaster situation. Each question will give you details on what you have assessed and you will need to use those details to help you assign a color tag to the individual: The wounded victim is unable to walk, has respiratory rate of 40, capillary refill is 6 seconds, and can't follow simple commands. The wounded victim is assigned what tag color? A. Green B. Red C. Yellow D. Black The answer is D: Black. The black tag is placed on the wounded that are dying or have expired. The injuries are so severe that death is imminent. There is severe alteration or absence of breathing, circulation, and neuro status. While triaging the wounded from a disaster, you note that one of the wounded is not breathing, radial pulse is absent, capillary refill >2 seconds, and does not respond to your commands. What color tag is assigned? A. Green B. Red C. Yellow D. Black The answer is B: Red. The wounded victim is unable to walk, has respiratory rate of 12, capillary refill is 8 seconds, and is unresponsive. The wounded victim is assigned what tag color? A. Green B. Red C. Yellow D. Black Downloaded by dowi educs (pallette@cpc.cx) lOMoARcPSD|36757530 The answer is C: Yellow. The wounded victim is unable to walk, has respiratory rate of 19, capillary refill of one second, and is able to obey your commands. The wounded victim is assigned what tag color? A. Green B. Red C. Yellow D. Black The answer is B: Red. 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? A. Green B. Red C. Yellow D. Black The answer is D: Black. The wounded victim is unable to walk, respiratory rate is absent and when airway is repositioned breathing is still absent. The wounded victim is assigned what tag color? A. Green B. Red C. Yellow D. Black The answer is A: Green. The wounded victim is able to walk and obey commands. The wounded victim is assigned what tag color? A. Green B. Red C. Yellow D. Black C 4, 3, 1, 2 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. 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 C 4, 3, 1, 2 D 3, 4, 2, 1 D Brief neurologic A brief neurologic assessment to determine the level of consciousness and pupil reaction is part of the primary survey. Vital signs, client's allergy, and initiation of pulse oximetry are considered part of the secondary survey. n conducting a primary survey on a trauma patient, which of the following is considered one of the priority elements of the primary survey? A Initiation of pulse oximetry. B Complete set of vital signs. C Client's allergy history. D Brief neurologic assessment. 00:0201:34 C. Emergent Chest pain is considered an emergent priority, which is defined as potentially lifethreatening. Option B: Clients with urgent priority need treatment within 2 hours of Downloaded by dowi educs (pallette@cpc.cx) lOMoARcPSD|36757530 triage (e.g. kidney stones). Option A: Nonurgent 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. 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. D 5, 1, 4, 3, 2 Establish unresponsiveness first. (The patient may have fallen and sustained a minor injury.) If the patient is unresponsive, get help and have someone initiate the code. Performing the chin lift or jaw thrust maneuver opens the airway. The nurse is then responsible for starting CPR. CPR should not be interrupted until the patient recovers or it is determined that heroic efforts have been exhausted. A crash cart should be at the site when the code team arrives; however, basic CPR can be effectively performed until the team arrives. You respond to a call for help from the ED waiting room. There is an elderly patient lying on the floor. List the order for the actions that you must perform. 1. Call for help and activate the code team. 2. Instruct a nursing assistant to get the emergency cart. 3. Initiate cardiopulmonary resuscitation (CPR). 4. Perform the chin lift or jaw thrust maneuver. 5. Establish unresponsiveness. A 5, 2, 4, 3, 1 B 1, 5, 2, 4, 3 C 1, 2, 5, 4, 3 D 5, 1, 4, 3, 2 A 5, 2, 1, 3, 4 B 2, 5, 1, 4, 3 C 2, 1, 5, 3, 4 D 3, 2, 1, 4, 5 You are caring for a client with a frostbite on the feet. Place the following interventions in the correct order. 1. Immerse the feet in warm water 100° F to 105° F (40.6º C to 46.1° C). 2. Remove the victim from the cold environment. 3. Monitor for signs of compartment syndrome. 4. Apply a loose, sterile, bulky dressing. 5. Administer a pain medication. A 5, 2, 1, 3, 4 B 2, 5, 1, 4, 3 C 2, 1, 5, 3, 4 D 3, 2, 1, 4, 5 D Monitor an asymptomatic near-drowning victim. The asymptomatic patient is currently stable but should be observed for delayed pulmonary edema, cerebral edema, or pneumonia. Options A and B: Teaching and care of critical patients are an RN responsibility. Option C: Removing clothing can be delegated to a nursing assistant. In relation to submersion injuries, which task is most appropriate to delegate to an LPN/LVN? A Talk to a community group about water safety issues. B Downloaded by dowi educs (pallette@cpc.cx) lOMoARcPSD|36757530 Stabilize the cervical spine for an unconscious drowning victim. C Remove wet clothing and cover the victim with a warm blanket. D Monitor an asymptomatic near-drowning victim. Downloaded by dowi educs (pallette@cpc.cx)
