NCLEX
NCLEX Disaster nursing- Exam
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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?
A
Non-urgent.
B
Urgent.
C
Emergent.
D
High urgent. - ANS ✓C. Emergent
Chest pain is considered an emergent priority, which is defined as
potentially life-threatening. Option B: Clients with urgent priority
need treatment within 2 hours of triage (e.g. kidney stones). Option A:
Non-urgent 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.
Disaster nursing- NCLEX
, 2
NCLEX
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 manoeuvre.
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 - ANS ✓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
manoeuvre 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 are caring for a client with a frostbite on the feet. Place the
following interventions in the correct order.
Disaster nursing- NCLEX