Focus on Delegating Prioritizing Triage
Disaster Exam Questions and Answers
100% Pass
A home care nurse is assigned to visit a prenatal client with a diagnosis of
hyperemesis gravidarum (HEG). During physical assessment of the client, the
nurse should first: - ANSWER-Assess the client's intake and output
Rationale: HEG is persistent, uncontrolled vomiting that begins before the 20th
week of pregnancy. It can have serious consequence, including loss of 5% of
prepregnancy weight, dehydration, ketosis, acid-base imbalance, and electrolyte
imbalances. Physical assessment begins with determining the client's intake and
output, because these data provide information regarding hydration and the
nutritional status of the client. The client's weight would be obtained and the
baseline value compared with previous and subsequent values. Additionally, the
nurse would instruct the client in how to accurately check and monitor her weight.
Laboratory data may need to be evaluated; increased hemoglobin and hematocrit
values may occur as a result of dehydration. Encouraging the client to verbalize her
©️COPYRIGHT 2025, ALL RIGHTS RESERVED. 1
,feelings about the diagnosis is a component of the plan of care but is not the first
intervention during physical assessment.
A nurse is monitoring a client with preeclampsia who is receiving intravenous
magnesium sulfate to prevent seizures. The nurse notes that the client's respiratory
rate is 10 breaths/min. On the basis of this finding, the nurse first: - ANSWER-
Discontinues the magnesium sulfate
Rationale: A respiratory rate slower than 12 breaths/min is a sign of magnesium
toxicity. Other signs include the absence of deep tendon reflexes, altered
sensorium, hypotension, and a serum magnesium level above the therapeutic range
of 5 to 8 mg/dL (2.05 to 3.29 mmol/L). In this situation, the nurse would first
discontinue the magnesium sulfate. The nurse would then take the client's vital
signs and contact the health care provider health care providerThe most recent
serum magnesium level may be checked; however, a current serum level would
provide more useful data.
A client who has just undergone abdominal surgery calls the nurse and states, "I
feel as if I just split open." The nurse checks the abdominal incision and finds
wound evisceration. The nurse immediately: - ANSWER-Contacts the health care
provider
©️COPYRIGHT 2025, ALL RIGHTS RESERVED. 2
,Rationale: Wound evisceration is the total separation of a surgical incision or
wound with extrusion of the internal organs or viscera through the open wound.
When evisceration occurs, the nurse immediately calls for help and has the health
care provider notified. The nurse stays with the client and positions the client with
the hips and knees bent. The nurse then covers the abdominal wound with a sterile
dressing moistened with sterile saline solution. The nurse would then take the
client's vital signs and document the occurrence. Since this is a surgical emergency,
the operating room would be notified but this would not be done until directed to
do so by the surgeon.
A client is receiving an intravenous (IV) infusion of 1000 mL of normal saline
solution at a rate of 125 mL/hr. The client suddenly complains of shortness of
breath, and the nurse notes the presence of dependent edema and puffiness
around the client's eyes. The nurse suspects circulatory overload and immediately: -
ANSWER-Slows the IV rate
Rationale: Signs of circulatory overload include shortness of breath, cough,
increased blood pressure, puffiness around the eyes, and edema in dependent
areas. The client's neck veins may be engorged, and the nurse may hear moist
breath sounds on auscultation of the lungs. If circulatory overload occurs, the
nurse must immediately slow the IV rate and then notify the health care provider.
©️COPYRIGHT 2025, ALL RIGHTS RESERVED. 3
, The client would be placed in an upright position. The nurse would monitor the
client's vital signs and administer oxygen and diuretics as prescribed.
A nurse is performing closed suctioning through a tracheostomy for a ventilator-
dependent client. During the procedure, the alarm on the cardiac monitor sounds
and the nurse notes severe bradycardia. The nurse stops suctioning the client and
immediately: - ANSWER-Oxygenates the client manually with 100% oxygen
Rationale: Suctioning is associated with several complications, including hypoxia,
tissue (mucosal) trauma, infection, vagal stimulation, and bronchospasm. Vagal
stimulation may result in severe bradycardia, hypotension, heart block, ventricular
tachycardia, or asystole. If vagal stimulation occurs, the nurse stops suctioning
immediately and oxygenates the client manually with 100% oxygen. Contacting the
respiratory therapist will delay the required and immediate intervention. Although
regular checks of the ventilator connections are the standard of care for a client
undergoing mechanical ventilation, doing so will not alleviate the client's problem
in this situation. An increase in PEEP is not indicated at this time.
Inner maxillary fixation (IMF) is performed on a client who sustained a mandibular
fracture in a motor vehicle crash. During an assessment, the client begins to vomit.
The nurse suctions the client but is unsuccessful, and the client exhibits signs of
hypoxia. The nurse immediately: - ANSWER-Cuts the mouth wires
©️COPYRIGHT 2025, ALL RIGHTS RESERVED. 4
Disaster Exam Questions and Answers
100% Pass
A home care nurse is assigned to visit a prenatal client with a diagnosis of
hyperemesis gravidarum (HEG). During physical assessment of the client, the
nurse should first: - ANSWER-Assess the client's intake and output
Rationale: HEG is persistent, uncontrolled vomiting that begins before the 20th
week of pregnancy. It can have serious consequence, including loss of 5% of
prepregnancy weight, dehydration, ketosis, acid-base imbalance, and electrolyte
imbalances. Physical assessment begins with determining the client's intake and
output, because these data provide information regarding hydration and the
nutritional status of the client. The client's weight would be obtained and the
baseline value compared with previous and subsequent values. Additionally, the
nurse would instruct the client in how to accurately check and monitor her weight.
Laboratory data may need to be evaluated; increased hemoglobin and hematocrit
values may occur as a result of dehydration. Encouraging the client to verbalize her
©️COPYRIGHT 2025, ALL RIGHTS RESERVED. 1
,feelings about the diagnosis is a component of the plan of care but is not the first
intervention during physical assessment.
A nurse is monitoring a client with preeclampsia who is receiving intravenous
magnesium sulfate to prevent seizures. The nurse notes that the client's respiratory
rate is 10 breaths/min. On the basis of this finding, the nurse first: - ANSWER-
Discontinues the magnesium sulfate
Rationale: A respiratory rate slower than 12 breaths/min is a sign of magnesium
toxicity. Other signs include the absence of deep tendon reflexes, altered
sensorium, hypotension, and a serum magnesium level above the therapeutic range
of 5 to 8 mg/dL (2.05 to 3.29 mmol/L). In this situation, the nurse would first
discontinue the magnesium sulfate. The nurse would then take the client's vital
signs and contact the health care provider health care providerThe most recent
serum magnesium level may be checked; however, a current serum level would
provide more useful data.
A client who has just undergone abdominal surgery calls the nurse and states, "I
feel as if I just split open." The nurse checks the abdominal incision and finds
wound evisceration. The nurse immediately: - ANSWER-Contacts the health care
provider
©️COPYRIGHT 2025, ALL RIGHTS RESERVED. 2
,Rationale: Wound evisceration is the total separation of a surgical incision or
wound with extrusion of the internal organs or viscera through the open wound.
When evisceration occurs, the nurse immediately calls for help and has the health
care provider notified. The nurse stays with the client and positions the client with
the hips and knees bent. The nurse then covers the abdominal wound with a sterile
dressing moistened with sterile saline solution. The nurse would then take the
client's vital signs and document the occurrence. Since this is a surgical emergency,
the operating room would be notified but this would not be done until directed to
do so by the surgeon.
A client is receiving an intravenous (IV) infusion of 1000 mL of normal saline
solution at a rate of 125 mL/hr. The client suddenly complains of shortness of
breath, and the nurse notes the presence of dependent edema and puffiness
around the client's eyes. The nurse suspects circulatory overload and immediately: -
ANSWER-Slows the IV rate
Rationale: Signs of circulatory overload include shortness of breath, cough,
increased blood pressure, puffiness around the eyes, and edema in dependent
areas. The client's neck veins may be engorged, and the nurse may hear moist
breath sounds on auscultation of the lungs. If circulatory overload occurs, the
nurse must immediately slow the IV rate and then notify the health care provider.
©️COPYRIGHT 2025, ALL RIGHTS RESERVED. 3
, The client would be placed in an upright position. The nurse would monitor the
client's vital signs and administer oxygen and diuretics as prescribed.
A nurse is performing closed suctioning through a tracheostomy for a ventilator-
dependent client. During the procedure, the alarm on the cardiac monitor sounds
and the nurse notes severe bradycardia. The nurse stops suctioning the client and
immediately: - ANSWER-Oxygenates the client manually with 100% oxygen
Rationale: Suctioning is associated with several complications, including hypoxia,
tissue (mucosal) trauma, infection, vagal stimulation, and bronchospasm. Vagal
stimulation may result in severe bradycardia, hypotension, heart block, ventricular
tachycardia, or asystole. If vagal stimulation occurs, the nurse stops suctioning
immediately and oxygenates the client manually with 100% oxygen. Contacting the
respiratory therapist will delay the required and immediate intervention. Although
regular checks of the ventilator connections are the standard of care for a client
undergoing mechanical ventilation, doing so will not alleviate the client's problem
in this situation. An increase in PEEP is not indicated at this time.
Inner maxillary fixation (IMF) is performed on a client who sustained a mandibular
fracture in a motor vehicle crash. During an assessment, the client begins to vomit.
The nurse suctions the client but is unsuccessful, and the client exhibits signs of
hypoxia. The nurse immediately: - ANSWER-Cuts the mouth wires
©️COPYRIGHT 2025, ALL RIGHTS RESERVED. 4
