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ATI ADULT MEDICAL SURGICAL NURSING – UNIT 14 Emergency Nursing &
Disaster Management 120 Questions with Rationales
SECTION 1: EMERGENCY NURSING PRINCIPLES & TRIAGE
1. A nurse is triaging clients after a mass casualty event. Which
client should be tagged as "emergent" (red)?
A. A client with a fractured arm and stable vital signs
B. A client with airway obstruction and respiratory distress
C. A client with minor lacerations and ambulatory
D. A client with no pulse and fixed dilated pupils
Answer: B
Rationale: Red tag indicates immediate life-threatening injury
requiring rapid intervention; airway obstruction is priority. A
fractured arm is yellow (urgent); minor lacerations are green
(nonurgent); no pulse with fixed pupils is black (deceased).
2. In the emergency department, which client should be seen
first?
A. A client with a laceration to the forearm and mild bleeding
B. A client with chest pain, diaphoresis, and shortness of breath
C. A client with a sprained ankle and pain 5/10
D. A client with a low-grade fever and sore throat
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Answer: B
Rationale: ABCs and life-threatening conditions take priority;
chest pain with diaphoresis and dyspnea suggests acute
coronary syndrome requiring immediate intervention.
3. A nurse is using the Emergency Severity Index (ESI) for triage.
Which client is ESI level 1?
A. A client with asthma exacerbation and wheezing
B. A client with a dislocated shoulder and pain
C. A client who is unresponsive, apneic, and pulseless
D. A client with abdominal pain and vomiting
Answer: C
Rationale: ESI-1 requires immediate life-saving intervention
(unresponsive, apneic, pulseless). ESI-2 is high-risk; ESI-3
requires multiple resources; ESI-4/5 are lower acuity.
4. The primary survey in emergency assessment includes which
components?
A. Airway, breathing, circulation, disability, exposure
B. Only vital signs
C. Only level of consciousness and pain
D. Full head-to-toe assessment only
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Answer: A
Rationale: The primary survey uses ABCDE: Airway, Breathing,
Circulation, Disability (neuro), Exposure (remove clothing to
assess).
5. A nurse is conducting a secondary survey on a trauma client.
Which action is included?
A. Head-to-toe assessment and history (AMPLE)
B. Only checking blood pressure
C. Only assessing airway
D. Only inserting IV lines
Answer: A
Rationale: The secondary survey is a complete head-to-toe
assessment after life threats are addressed; AMPLE history
(Allergies, Medications, Past history, Last meal, Events).
6. Which of the following is the priority intervention for a client
with an obstructed airway?
A. Obtain a chest X-ray
B. Perform head-tilt-chin-lift or jaw thrust and suction as
needed
C. Administer oral fluids
D. Apply oxygen via nasal cannula only
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Answer: B
Rationale: Airway management is priority; open airway, clear
secretions, and provide oxygen.
7. A client arrives in the ED after a motor vehicle crash with a
cervical collar in place. The nurse should:
A. Remove the collar to assess the neck
B. Maintain cervical spine immobilization until cleared
C. Allow the client to move the neck freely
D. Apply heat to the neck
Answer: B
Rationale: Until cervical spine injury is ruled out, immobilization
is maintained.
8. Which of the following is a sign of tension pneumothorax?
A. Tracheal deviation away from the affected side, absent
breath sounds, and hypotension
B. Bilateral crackles
C. Normal breath sounds
D. Bradycardia only
Answer: A
Rationale: Tension pneumothorax shifts the mediastinum,
ATI ADULT MEDICAL SURGICAL NURSING – UNIT 14 Emergency Nursing &
Disaster Management 120 Questions with Rationales
SECTION 1: EMERGENCY NURSING PRINCIPLES & TRIAGE
1. A nurse is triaging clients after a mass casualty event. Which
client should be tagged as "emergent" (red)?
A. A client with a fractured arm and stable vital signs
B. A client with airway obstruction and respiratory distress
C. A client with minor lacerations and ambulatory
D. A client with no pulse and fixed dilated pupils
Answer: B
Rationale: Red tag indicates immediate life-threatening injury
requiring rapid intervention; airway obstruction is priority. A
fractured arm is yellow (urgent); minor lacerations are green
(nonurgent); no pulse with fixed pupils is black (deceased).
2. In the emergency department, which client should be seen
first?
A. A client with a laceration to the forearm and mild bleeding
B. A client with chest pain, diaphoresis, and shortness of breath
C. A client with a sprained ankle and pain 5/10
D. A client with a low-grade fever and sore throat
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Answer: B
Rationale: ABCs and life-threatening conditions take priority;
chest pain with diaphoresis and dyspnea suggests acute
coronary syndrome requiring immediate intervention.
3. A nurse is using the Emergency Severity Index (ESI) for triage.
Which client is ESI level 1?
A. A client with asthma exacerbation and wheezing
B. A client with a dislocated shoulder and pain
C. A client who is unresponsive, apneic, and pulseless
D. A client with abdominal pain and vomiting
Answer: C
Rationale: ESI-1 requires immediate life-saving intervention
(unresponsive, apneic, pulseless). ESI-2 is high-risk; ESI-3
requires multiple resources; ESI-4/5 are lower acuity.
4. The primary survey in emergency assessment includes which
components?
A. Airway, breathing, circulation, disability, exposure
B. Only vital signs
C. Only level of consciousness and pain
D. Full head-to-toe assessment only
, Page |3
Answer: A
Rationale: The primary survey uses ABCDE: Airway, Breathing,
Circulation, Disability (neuro), Exposure (remove clothing to
assess).
5. A nurse is conducting a secondary survey on a trauma client.
Which action is included?
A. Head-to-toe assessment and history (AMPLE)
B. Only checking blood pressure
C. Only assessing airway
D. Only inserting IV lines
Answer: A
Rationale: The secondary survey is a complete head-to-toe
assessment after life threats are addressed; AMPLE history
(Allergies, Medications, Past history, Last meal, Events).
6. Which of the following is the priority intervention for a client
with an obstructed airway?
A. Obtain a chest X-ray
B. Perform head-tilt-chin-lift or jaw thrust and suction as
needed
C. Administer oral fluids
D. Apply oxygen via nasal cannula only
, Page |4
Answer: B
Rationale: Airway management is priority; open airway, clear
secretions, and provide oxygen.
7. A client arrives in the ED after a motor vehicle crash with a
cervical collar in place. The nurse should:
A. Remove the collar to assess the neck
B. Maintain cervical spine immobilization until cleared
C. Allow the client to move the neck freely
D. Apply heat to the neck
Answer: B
Rationale: Until cervical spine injury is ruled out, immobilization
is maintained.
8. Which of the following is a sign of tension pneumothorax?
A. Tracheal deviation away from the affected side, absent
breath sounds, and hypotension
B. Bilateral crackles
C. Normal breath sounds
D. Bradycardia only
Answer: A
Rationale: Tension pneumothorax shifts the mediastinum,
