Emergency Triage Practice UPDATED
ACTUAL Exam Questions and CORRECT
Answers
A hospital responds to a local mass casualty event. Which action should the nurse supervisor take
to prevent staff post-traumatic stress disorder during a mass casualty event?
a. Provide water and healthy snacks for energy throughout the event.
b. Schedule 16-hour shifts to allow for greater rest between shifts.
c. Encourage counseling upon deactivation of the emergency response plan.
d. Assign staff to different roles and units within the medical facility. - CORRECT
ANSWER -A
To prevent staff post-traumatic stress disorder during a mass casualty event, the nurses should
use available counseling, encourage and support co-workers, monitor each others stress level and
performance, take breaks when needed, talk about feelings with staff and managers, and drink
plenty of water and eat healthy snacks for energy. Nurses should also keep in touch with family,
friends, and significant others, and not work for more than 12 hours per day. Encouraging
counseling upon deactivation of the plan, or after the emergency response is over, does not
prevent stress during the casualty event. Assigning staff to unfamiliar roles or units may increase
situational stress and is not an approach to prevent post-traumatic stress disorder.
A client who is hospitalized with burns after losing the family home in a fire becomes angry and
screams at a nurse when dinner is served late. How should the nurse respond?
a. Do you need something for pain right now?
b. Please stop yelling. I brought dinner as soon as I could.
c. I suggest that you get control of yourself.
d. You seem upset. I have time to talk if you'd like. - CORRECT ANSWER -D
Clients should be allowed to ventilate their feelings of anger and despair after a catastrophic
event. The nurse establishes rapport through active listening and honest communication and by
recognizing cues that the client wishes to talk. Asking whether the client is in pain as the first
response closes the door to open communication and limits the clients options. Simply telling the
client to stop yelling and to gain control does nothing to promote therapeutic communication.
,A nurse is field-triaging clients after an industrial accident. Which client condition should the
nurse triage with a red tag?
a. Dislocated right hip and an open fracture of the right lower leg
b. Large contusion to the forehead and a bloody nose
c. Closed fracture of the right clavicle and arm numbness
d. Multiple fractured ribs and shortness of breath - CORRECT ANSWER -D
Clients who have an immediate threat to life are given the highest priority, are placed in the
emergent or class I category, and are given a red triage tag. The client with multiple rib fractures
and shortness of breath most likely has developed a pneumothorax, which may be fatal if not
treated immediately. The client with the hip and leg problem and the client with the clavicle
fracture would be classified as class II; these major but stable injuries can wait 30 minutes to 2
hours for definitive care. The client with facial wounds would be considered the walking
wounded and classified as nonurgent.
An emergency department (ED) charge nurse prepares to receive clients from a mass casualty
within the community. What is the role of this nurse during the event?
a. Ask ED staff to discharge clients from the medical-surgical units in order to make room for
critically injured victims.
b. Call additional medical-surgical and critical care nursing staff to come to the hospital to assist
when victims are brought in.
c. Inform the incident commander at the mass casualty scene about how many victims may be
handled by the ED.
d. Direct medical-surgical and critical care nurses to assist with clients currently in the ED while
emergency staff prepare to receive the mass casualty victims. - CORRECT ANSWER -D
The ED charge nurse should direct additional nursing staff to help care for current ED clients
while the ED staff prepares to receive mass casualty victims; however, they should not be
assigned to the most critically ill or injured clients. The house supervisor and unit directors
would collaborate to discharge stable clients. The hospital incident commander is responsible for
mobilizing resources and would have the responsibility for calling in staff. The medical
command physician would be the person best able to communicate with on-scene personnel
regarding the ability to take more clients.
,The hospital administration arranges for critical incident stress debriefing for the staff after a
mass casualty incident. Which statement by the debriefing team leader is most appropriate for
this situation?
a. You are free to express your feelings; whatever is said here stays here.
b. Lets evaluate what went wrong and develop policies for future incidents.
c. This session is only for nursing and medical staff, not for ancillary personnel.
d. Lets pass around the written policy compliance form for everyone. - CORRECT
ANSWER -A
Strict confidentiality during stress debriefing is essential so that staff members can feel
comfortable sharing their feelings, which should be accepted unconditionally. Brainstorming
improvements and discussing policies would occur during an administrative review. Any
employee present during a mass casualty situation is eligible for critical incident stress
management services.
A nurse cares for clients during a community-wide disaster drill. Once of the clients asks, "Why
are the individuals with black tags not receiving any care?" How should the nurse respond?
a. To do the greatest good for the greatest number of people, it is necessary to sacrifice some.
b. Not everyone will survive a disaster, so it is best to identify those people early and move on.
c. In a disaster, extensive resources are not used for one person at the expense of many others.
d. With black tags, volunteers can identify those who are dying and can give them comfort care. -
CORRECT ANSWER -C
In a disaster, military-style triage is used; this approach identifies the dead or expectant dead
with black tags. This practice helps to maintain the goal of triage, which is doing the most good
for the most people. Precious resources are not used for those with overwhelming critical injury
or illness, so that they can be allocated to others who have a reasonable expectation of survival.
Clients are not sacrificed. Telling students to move on after identifying the expectant dead
belittles their feelings and does not provide an adequate explanation. Clients are not black-tagged
to allow volunteers to give comfort care.
After a hospitals emergency department (ED) has efficiently triaged, treated, and transferred
clients from a community disaster to appropriate units, the hospital incident command officer
, wants to stand down from the emergency plan. Which question should the nursing supervisor ask
at this time?
a. Are you sure no more victims are coming into the ED?
b. Do all areas of the hospital have the supplies and personnel they need?
c. Have all ED staff had the chance to eat and rest recently?
d. Does the Chief Medical Officer agree this disaster is under control? - CORRECT
ANSWER -B
Before standing down, the incident command officer ensures that the needs of the other hospital
departments have been taken care of because they may still be stressed and may need continued
support to keep functioning. Many more walking wounded victims may present to the ED; that
number may not be predictable. Giving staff the chance to eat and rest is important, but all areas
of the facility need that too. Although the Chief Medical Officer (CMO) may be involved in the
incident, the CMO does not determine when the hospital can stand down.
An emergency department charge nurse notes an increase in sick calls and bickering among the
staff after a week with multiple trauma incidents. Which action should the nurse take?
a. Organize a pizza party for each shift.
b. Remind the staff of the facility's sick-leave policy.
c. Arrange for critical incident stress debriefing.
d. Talk individually with staff members. - CORRECT ANSWER -C
The staff may be suffering from critical incident stress and needs to have a debriefing by the
critical incident stress management team to prevent the consequences of long-term, unabated
stress. Speaking with staff members individually does not provide the same level of support as a
group debriefing. Organizing a party and revisiting the sick-leave policy may be helpful, but are
not as important and beneficial as a debriefing.
Emergency medical services (EMS) brings a large number of clients to the emergency
department following a mass casualty incident. The nurse identifies the clients with which
injuries with yellow tags? Select All That Apply
a. Partial-thickness burns covering both legs
b. Open fractures of both legs with absent pedal pulses
ACTUAL Exam Questions and CORRECT
Answers
A hospital responds to a local mass casualty event. Which action should the nurse supervisor take
to prevent staff post-traumatic stress disorder during a mass casualty event?
a. Provide water and healthy snacks for energy throughout the event.
b. Schedule 16-hour shifts to allow for greater rest between shifts.
c. Encourage counseling upon deactivation of the emergency response plan.
d. Assign staff to different roles and units within the medical facility. - CORRECT
ANSWER -A
To prevent staff post-traumatic stress disorder during a mass casualty event, the nurses should
use available counseling, encourage and support co-workers, monitor each others stress level and
performance, take breaks when needed, talk about feelings with staff and managers, and drink
plenty of water and eat healthy snacks for energy. Nurses should also keep in touch with family,
friends, and significant others, and not work for more than 12 hours per day. Encouraging
counseling upon deactivation of the plan, or after the emergency response is over, does not
prevent stress during the casualty event. Assigning staff to unfamiliar roles or units may increase
situational stress and is not an approach to prevent post-traumatic stress disorder.
A client who is hospitalized with burns after losing the family home in a fire becomes angry and
screams at a nurse when dinner is served late. How should the nurse respond?
a. Do you need something for pain right now?
b. Please stop yelling. I brought dinner as soon as I could.
c. I suggest that you get control of yourself.
d. You seem upset. I have time to talk if you'd like. - CORRECT ANSWER -D
Clients should be allowed to ventilate their feelings of anger and despair after a catastrophic
event. The nurse establishes rapport through active listening and honest communication and by
recognizing cues that the client wishes to talk. Asking whether the client is in pain as the first
response closes the door to open communication and limits the clients options. Simply telling the
client to stop yelling and to gain control does nothing to promote therapeutic communication.
,A nurse is field-triaging clients after an industrial accident. Which client condition should the
nurse triage with a red tag?
a. Dislocated right hip and an open fracture of the right lower leg
b. Large contusion to the forehead and a bloody nose
c. Closed fracture of the right clavicle and arm numbness
d. Multiple fractured ribs and shortness of breath - CORRECT ANSWER -D
Clients who have an immediate threat to life are given the highest priority, are placed in the
emergent or class I category, and are given a red triage tag. The client with multiple rib fractures
and shortness of breath most likely has developed a pneumothorax, which may be fatal if not
treated immediately. The client with the hip and leg problem and the client with the clavicle
fracture would be classified as class II; these major but stable injuries can wait 30 minutes to 2
hours for definitive care. The client with facial wounds would be considered the walking
wounded and classified as nonurgent.
An emergency department (ED) charge nurse prepares to receive clients from a mass casualty
within the community. What is the role of this nurse during the event?
a. Ask ED staff to discharge clients from the medical-surgical units in order to make room for
critically injured victims.
b. Call additional medical-surgical and critical care nursing staff to come to the hospital to assist
when victims are brought in.
c. Inform the incident commander at the mass casualty scene about how many victims may be
handled by the ED.
d. Direct medical-surgical and critical care nurses to assist with clients currently in the ED while
emergency staff prepare to receive the mass casualty victims. - CORRECT ANSWER -D
The ED charge nurse should direct additional nursing staff to help care for current ED clients
while the ED staff prepares to receive mass casualty victims; however, they should not be
assigned to the most critically ill or injured clients. The house supervisor and unit directors
would collaborate to discharge stable clients. The hospital incident commander is responsible for
mobilizing resources and would have the responsibility for calling in staff. The medical
command physician would be the person best able to communicate with on-scene personnel
regarding the ability to take more clients.
,The hospital administration arranges for critical incident stress debriefing for the staff after a
mass casualty incident. Which statement by the debriefing team leader is most appropriate for
this situation?
a. You are free to express your feelings; whatever is said here stays here.
b. Lets evaluate what went wrong and develop policies for future incidents.
c. This session is only for nursing and medical staff, not for ancillary personnel.
d. Lets pass around the written policy compliance form for everyone. - CORRECT
ANSWER -A
Strict confidentiality during stress debriefing is essential so that staff members can feel
comfortable sharing their feelings, which should be accepted unconditionally. Brainstorming
improvements and discussing policies would occur during an administrative review. Any
employee present during a mass casualty situation is eligible for critical incident stress
management services.
A nurse cares for clients during a community-wide disaster drill. Once of the clients asks, "Why
are the individuals with black tags not receiving any care?" How should the nurse respond?
a. To do the greatest good for the greatest number of people, it is necessary to sacrifice some.
b. Not everyone will survive a disaster, so it is best to identify those people early and move on.
c. In a disaster, extensive resources are not used for one person at the expense of many others.
d. With black tags, volunteers can identify those who are dying and can give them comfort care. -
CORRECT ANSWER -C
In a disaster, military-style triage is used; this approach identifies the dead or expectant dead
with black tags. This practice helps to maintain the goal of triage, which is doing the most good
for the most people. Precious resources are not used for those with overwhelming critical injury
or illness, so that they can be allocated to others who have a reasonable expectation of survival.
Clients are not sacrificed. Telling students to move on after identifying the expectant dead
belittles their feelings and does not provide an adequate explanation. Clients are not black-tagged
to allow volunteers to give comfort care.
After a hospitals emergency department (ED) has efficiently triaged, treated, and transferred
clients from a community disaster to appropriate units, the hospital incident command officer
, wants to stand down from the emergency plan. Which question should the nursing supervisor ask
at this time?
a. Are you sure no more victims are coming into the ED?
b. Do all areas of the hospital have the supplies and personnel they need?
c. Have all ED staff had the chance to eat and rest recently?
d. Does the Chief Medical Officer agree this disaster is under control? - CORRECT
ANSWER -B
Before standing down, the incident command officer ensures that the needs of the other hospital
departments have been taken care of because they may still be stressed and may need continued
support to keep functioning. Many more walking wounded victims may present to the ED; that
number may not be predictable. Giving staff the chance to eat and rest is important, but all areas
of the facility need that too. Although the Chief Medical Officer (CMO) may be involved in the
incident, the CMO does not determine when the hospital can stand down.
An emergency department charge nurse notes an increase in sick calls and bickering among the
staff after a week with multiple trauma incidents. Which action should the nurse take?
a. Organize a pizza party for each shift.
b. Remind the staff of the facility's sick-leave policy.
c. Arrange for critical incident stress debriefing.
d. Talk individually with staff members. - CORRECT ANSWER -C
The staff may be suffering from critical incident stress and needs to have a debriefing by the
critical incident stress management team to prevent the consequences of long-term, unabated
stress. Speaking with staff members individually does not provide the same level of support as a
group debriefing. Organizing a party and revisiting the sick-leave policy may be helpful, but are
not as important and beneficial as a debriefing.
Emergency medical services (EMS) brings a large number of clients to the emergency
department following a mass casualty incident. The nurse identifies the clients with which
injuries with yellow tags? Select All That Apply
a. Partial-thickness burns covering both legs
b. Open fractures of both legs with absent pedal pulses
