MS 2 Exam 1: Emergency Nursing With
Complete Solutions
Highest priority in the following patients:
a) Pulse Ox 95%
b) Temp of 39.2
c) Epiglottis, drooling, no cough
d) Sickle cell w/ pain 7 out of 10 - ANSWER C. Epiglottis, drooling, no cough
This can mean a patient can aspirate or stop breathing and can be dangerous
Which agencies do our include in an emergency response plan? (Hint: normally
don't contact federal government until at least 3 days. Need enough in
emergency response plan to sustain 3 days) - ANSWER CAMP POV
-CDC
-American Red Cross
-Metropolitan Medical Response Team
-Public Health Service
-Poison Control
-Office of emergency management (OEM)
-Volunteer led agencies
Working in the ER, patient comes in with multiple system trauma which is the
priority focus of care? - ANSWER Airway
Who can serve as a triage officer during a disaster? - ANSWER Experienced ED
nurses, physicians, or EMS (on scene)
Triaging 4 clients in the ER after a factory explosion, which client would the
nurse care for first? (Disaster nursing triage - greatest good for the greatest
number of people)
A) SOB, RR of 20, cap refill less than 2 sec
B) Unconscious client w/ a sucking chest wound, RR 38, cap refill less than 2
C) Conscious patient w/ a dislocated shoulder, normal RR and cap refill
D) Unconscious client w/ no resp, cap refill greater than 2, paramedics have
already tried to reposition airway - ANSWER B) Unconscious client w/ a sucking
chesst wound, RR 38, cap refill less than 2
Using the ESI (emergency severity index) following a bus accident who would
the healthcare provider see first? - ANSWER The ESI assigns patients into 5
, levels, LEVEL 1 (most urgent) to Level 5 (least urgent) based on acuity and
anticipated resource needs
LEVEL 1= resuscitative constant supervision
Following an outdoor picnic your patient has come to the ER with severe
vomiting and diarrhea. Suspecting food poisoning, what would your first 4
interventions be? - ANSWER -Collect samples for examination
-monitor vitals
-monitor/give fluids and electrolytes
-give antiemetic
In the ER, patient comes in with a snake bite. Client believes snake to be
venomous. The nurse anticipates antivenin to be administered, which following
intervention should the nurse take? (ATI Ch2) - ANSWER - The decision to
administer antivenin depends on worsening tissue injury or evidence of systemic
and coagulating symptoms
-ensure it is between the 4-12 hour mark
-Measure circumference of the affected area, and monitor for serum sickness or
allergic reaction
-provide measure for respiratory support
-Monitor compromised circulation
*Stay w/patient, check allergies, monitor for reaction and vitals*
Plan of care for ER, patient with 3rd degree frost bite? - ANSWER *Debridement,
rewarming, tetanus toxoid*
-debridement of damaged tissuse
-requires rewarming
-bathing affected areas in warm bath (104 to 108) will improve circulation and
promote healing of damaged tissue (can increase pain)
-Administer toxoid
A client collapsed on the field after playing football on a hot day. Review normal
sodium, potassium, chloride, glucose, BUN, and creatinine levels - ANSWER Na:
135-145
K: 3.5-5
Cl: 97-107
Glucose: 70-100
BUN: 10-20
Creatinine: 0.7-1.3 men
Complete Solutions
Highest priority in the following patients:
a) Pulse Ox 95%
b) Temp of 39.2
c) Epiglottis, drooling, no cough
d) Sickle cell w/ pain 7 out of 10 - ANSWER C. Epiglottis, drooling, no cough
This can mean a patient can aspirate or stop breathing and can be dangerous
Which agencies do our include in an emergency response plan? (Hint: normally
don't contact federal government until at least 3 days. Need enough in
emergency response plan to sustain 3 days) - ANSWER CAMP POV
-CDC
-American Red Cross
-Metropolitan Medical Response Team
-Public Health Service
-Poison Control
-Office of emergency management (OEM)
-Volunteer led agencies
Working in the ER, patient comes in with multiple system trauma which is the
priority focus of care? - ANSWER Airway
Who can serve as a triage officer during a disaster? - ANSWER Experienced ED
nurses, physicians, or EMS (on scene)
Triaging 4 clients in the ER after a factory explosion, which client would the
nurse care for first? (Disaster nursing triage - greatest good for the greatest
number of people)
A) SOB, RR of 20, cap refill less than 2 sec
B) Unconscious client w/ a sucking chest wound, RR 38, cap refill less than 2
C) Conscious patient w/ a dislocated shoulder, normal RR and cap refill
D) Unconscious client w/ no resp, cap refill greater than 2, paramedics have
already tried to reposition airway - ANSWER B) Unconscious client w/ a sucking
chesst wound, RR 38, cap refill less than 2
Using the ESI (emergency severity index) following a bus accident who would
the healthcare provider see first? - ANSWER The ESI assigns patients into 5
, levels, LEVEL 1 (most urgent) to Level 5 (least urgent) based on acuity and
anticipated resource needs
LEVEL 1= resuscitative constant supervision
Following an outdoor picnic your patient has come to the ER with severe
vomiting and diarrhea. Suspecting food poisoning, what would your first 4
interventions be? - ANSWER -Collect samples for examination
-monitor vitals
-monitor/give fluids and electrolytes
-give antiemetic
In the ER, patient comes in with a snake bite. Client believes snake to be
venomous. The nurse anticipates antivenin to be administered, which following
intervention should the nurse take? (ATI Ch2) - ANSWER - The decision to
administer antivenin depends on worsening tissue injury or evidence of systemic
and coagulating symptoms
-ensure it is between the 4-12 hour mark
-Measure circumference of the affected area, and monitor for serum sickness or
allergic reaction
-provide measure for respiratory support
-Monitor compromised circulation
*Stay w/patient, check allergies, monitor for reaction and vitals*
Plan of care for ER, patient with 3rd degree frost bite? - ANSWER *Debridement,
rewarming, tetanus toxoid*
-debridement of damaged tissuse
-requires rewarming
-bathing affected areas in warm bath (104 to 108) will improve circulation and
promote healing of damaged tissue (can increase pain)
-Administer toxoid
A client collapsed on the field after playing football on a hot day. Review normal
sodium, potassium, chloride, glucose, BUN, and creatinine levels - ANSWER Na:
135-145
K: 3.5-5
Cl: 97-107
Glucose: 70-100
BUN: 10-20
Creatinine: 0.7-1.3 men
